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Presented  by 
Patrick  S  O'Reilly,   D.   0 


COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 


AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


Y^^9^^fOKn^^  f^Jt^N 


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TWO-THIRDS    NATURAL    SIZE. 

BAZZI-BIAIMCHI    PHON  EN  DOSCOPE. 

WITH  OUTER  DISK  REMOVED. 


TRANSLATION   OF   LECTURES    DELIV^R^D    BY 

AURELIO  BIANCHI,  M.D.,      -      -     -      Parma. 

Professor  of  Preparatory  Clinical  Medicine  and  of  Pathology, 


THEPHONENDOSCOPE 

L— • — 

AND 

ITS  PRACTICAL  APPLICATION.^1 


(Chapters  I,  II  and  III  of  this  book  are  the  English  translation  of  lectures  delivered  by 

Professor  Aurelio  Bianchi,  and  it  is  the  direct  intention  of  the  publishers 

that  this  book  shall  not  be  mistaken  for  the  complete  book 

on  Phonendoscopy  in  course  of  preparation  ) 


With  Thirty-seven  Illustrations. 


WITH    TRANSLATIONS   OF    SPECIAL    ARTICLES    BY 

FELIX  REGNAUI/T,  M.D., France. 

M.  ANASTASIADES,  M.  D., Greece. 


TRANSLATED    BY 


A.  GEORGE  BAKER,  A.  M.  M.  D., 

Physician  in-Chief  of  the  Chinese  Medical  Dispensary,  Philadelphia,  and  author  of 

prize  essays  entitled  "  The  Revival  of  Learning,1'  and 

"  The  Germans  in  America,''  Etc. 


This  book  may  be  procured  in  Europe  from 
Martin  Wallach,  Nachfolger,  Cassel,  Germany. 


PHILADELPHIA,  U.  S.  A. 

GEORGE  P.  PILUNG  &  SON. 
1898. 


Copyrighted  1898,  by 
George  P.  Pilling  &  Son, 

Philadelphia. 
All  rights  reserved. 


Y  H  S 

PREFACE. 


The  instrument  which  Professor  Eugenic  Baz/,i  and  myself 
introduced  at  the  International  Medical  Congress  in  Rome,  in 
April,  1894,  and  to  which  we  gave  an  absolutely  new  name 
— that  of  "  Phonendoscope  " — has  quickly  and  permanently 
proven  to  be  a  substitute  for  the  old  Stethoscope,  because  it 
answered  the  purposes  of  the  semiological  examinations  of  to- 
day much  better  than  it  does. 

It  was,  therefore,  but  natural  that  it  should  have  found 
many  warm  friends,  and  that  former  opponents  have  since  been 
converted  to  its  use,  and  that  a  number  of  imitators  and  would- 
be  improvers  should  have  put  in  an  appearance. 

A  work  of  this  kind  must  necessarily  speak  of  two  sub- 
jects, the  one  referring  to  the  past,  and  mentioning  all  those, 
who  by  changing  the  old  Stethoscope,  brought  about  the  per- 
fection and  advance  in  the  construction  and  effect  of  that 
instrument ;  the  other  must  refer  to  the  present,  speaking  of 
those  who  have  imitated  our  instrument  and  changed  it. 

The  first  part  of  the  subject  exhausts  itself  just  here  ;  but 
the  second  can  only  be  commenced  later  on,  if  any  occasion 
should  arise,  and  may  be  continued  by  ourselves. 

I  am  not  driven  to  this  work  by  the  thought  of  useless 
historical  research  or  criticism,  but  by  the  necessity  of  setting 
right  all  features  in  their  relations  to  each  other  to  give  each 
one  his  dues,  which  he  deserves,  in  the  accomplishment  and 
use  of  the  means  of  examining  the  sounds  of  the  human 
organs,  and  to  prevent  others,  who  do  not  understand  the  sci- 
entific principles  which  are  embodied  in  our  apparatus,  from 
getting  the  wrong  impression,  and  from  believing  that  it  origin- 
ated not  by  the  thorough  application  and  considerable  study  of 
many  years,  but  that  it  owes  its  existence  to  a  mere  adoption 
of  the  researches  of  others. 

To  come  to  a  clear  understanding  as  to  what  our  instru- 
ment ought  to  be,  it  took  me  nearly  fifteen  years  of  study  and 
comparative  examinations.  Prof.  Bazzi,  who  was  willing  to 
try  and  give  my  idea  a  practical  form,  was  required  to  make 
many  experiments  and  trials,  and  only  after  careful  and  patient 
study  did  we  feel  satisfied  with  our  apparatus. 

Prof.  Bazzi  in  constructing  the  instrument  put  into  it  his 
profound  knowledge  of  the  physical  laws,  and  I  all  the  love 
and  practical  experience  which  I  had  acquired  in  this  field,  by 
the  constant  and  faithful  study  of  the  human  organs. 

AURELIO  BIANCHI,  M.D. 


TRANSLATOR'S  PREFACE. 


In  making  the  following  translations  it  has  been  my  aim 
and  object  always  to  present  the  ideas  of  the  various  authors, 
as  they  were  presented  in  the  original  productions. 

Anyone  familiar  with  one  or  more  of  the  languages  used 
on  the  Continent  of  Europe  will  appreciate  the  fact,  when  I 
say,  that  besides  the  languages  in  use  among  the  ordinary 
people  there  is  a  so-called  "University  Tongue."  This  all 
professors  think  it  their  duty  to  use  in  their  lectures  and 
various  literary  productions.  This  "  University  Tongue  "  is 
somewhat  confusing  to  the  ordinary  scholar,  who  may  be  able 
to  read  and  speak  the  vernacular  of  the  people.  It  seems  to  be 
the  aim  of  all  these  professors  to  frame  their  sentences  in  a 
peculiar  way,  and  with  many  circumlocutions,  often  covering 
a  whole  page  or  more  by  one  single  sentence.  The  ordinary 
reader  is  sure  to  forget  the  subject  with  which  the  sentence 
started  by  the  time  he  gets  to  the  end  of  it.  We  Americans 
do  not  express  our  thoughts  after  this  fashion.  Our  sentences, 
even  in  works  of  a  technical  character,  are  mostly  short  and 
plain,  so  that  he  who  reads  may  understand. 

In  the  following  pages  I  have  tried  to  avoid  these  compli- 
cations. I  have  tried,  however,  in  every  case,  to  give  the 
exact  idea  and  meaning  of  the  author.  I  have  also  endeavored 
to  render  the  ideas  in  an  idiom  which  is  easy  to  follow,  and  as 
nearly  to  our  accepted  standard  as  possible.  Each  language 
has  its  own  peculiar  idiom.  In  translating  articles,  therefore, 
which  were  written  by  authors  belonging  to  different  nationali- 
ties, the  greatest  care  is  required  by  the  translator,  so  as  not  to 
tall  into  their  way  of  constructing  his  sentences,  but  to  remain 
true  to  "Uncle  Sam's"  pure  American  way  of  expressing 
himself.  I  leave  it  to  the  reader  to  judge  how  far  I  have  suc- 
ceeded in  this  my  arduous  undertaking.  Hoping  that  all  who 
read  this  little  volume  may  derive  the  benefit  which  it  is  in- 
tended to  convey,  I  remain, 

Yours  truly, 

A.  GEORGE  BAKER,  A.  M.  M.  D., 

The  Translator. 


CONTENTS, 


CHAPTER   I. 
The  Phonendoscope  and  its  Practical  Application 9 

CHAPTER  II. 

Phonendoscopy  of  the  Organs  Especially  Concerning  the  Stom- 
ach and  its  Contents,  with  Experiments 22 

CHAPTER  III. 

Phonendoscopy  and  Outlines  of  the  Various  Organs,  with  Thir- 
teen Illustrations 34 

CHAPTER  IV. 

The  Relation  Between  the  Outlines  of  the  Internal  Organs  of 
the  Body  as  Determined  by  the  X-Raj^s  and  by  the  Phonen- 
doscope   50 

CHAPTER  V. 
Mechanical  Description  of  the  Phonendoscope 59 


The  Phonendoscope  and  the  Digestion  of  Fluids      ....         63 

By  Felix  Kegnault,  M.D. 


Application  of  the  Phonendoscope  in  the  Course  of  Pregnancy  69 

By  M.  Aiiastasiades,  M.D. 


LIST  OF  ILLUSTRATIONS. 


The  Phonendoscope Frontispiece 

Phonendoscopic  Figure  of  Lungs -34 

Phonendoscopic  Figure  of  Heart 35 

Phonendoscopic  Figure  of  Lungs  and  Heart 36 

Phonendoscopic  Figure  of  Liver  and  Colon      .     .     .     .    -.     .     -37 

Phonendoscopic  Figure  of  Stomach  and  Colon 38 

Phonendoscopic  Figure  of  Front  Side  of  Body     .....   39 
Phonendoscopic  Figure  of  Front  Side  of  Body,   with  Examina- 
tion of  Points 40 

Phonendoscopic  Figure  cf  Back  Side  of  Body,  with  Examina- 
tion of  Points 41 

Phonendoscopy  of  Natural  Vibrations 42 

Phonendoscopy  of  Muscular  Sounds       .  43 

Phonendoscopy  of  Vibrations,  Artificially  Produced      .     .     .     .44 

Phonendoscopy  of  Larynx 45 

Phonendoscopy  of  Vibrations,  Artificially  Produced      ....   46 

Comparative  Phonendoscopy     .  47 

Phonendoscopic  Examination  of  Horse ^48 

Forked  Attachments  for  the  Phonendoscope 49 

vSectional  View  of  Phonendoscope .58 

Prof.   Bianchi  Obtaining  Outlines  of   Liver  by  Means  of  the 

Phonendoscope 62 

Digestion  of  Water.  Wine,  Seltzer  Water  and  Tea  (twelve  illus- 
trations)   67 

Phonendoscopic  Figure  Showing  Points  of  Application  to  the 

Course  of  Pregnancy 68 

Phonendoscopic  Figure  Showing  Points  of  Application  to  the 

Course  of  Pregnancy  (Fig.  2) 70 

Schema  (or  Figure)  Representing  the  Greater  and  Lesser  Ex- 
tremity  and   Size   of  a  Fo3tus   in    a   Pregnancy  of  Eight 

Months,  Left  Position 72 

Schema  Representing  a  Gemillaire  or  Twin  Pregnancy  of  Eight 

and  a  half  Months,  Amniotic  Liquid  in  Excess      ....    74 
Foetal  Schema,  Right  Position,  Pregnancy   Complete,    Abdomi- 
nal Wall  very  Thick 76 


CHAPTER  I. 


THE  PHONENDOSCOPE  AND  ITS  PRACTICAL 
APPLICATION. 

By  Professor  Aurelio  Bianchi, 

One  of  the  principal  endeavors  of  the  learned  men  of  the 
present  century  was  directed  towards  the  discovery  of  some- 
thing which  should  carry  to  the  ear  of  the  examiner  the 
sounds  by  which  the  internal  processes  and  changes  might  be 
determined. 

It  may  be  asserted,  with  truth,  that  the  whole  basis  of 
this  principle  of  Semiotics,  insofar  as  the  same  rests  upon  the 
different  sounds  which  are  produced  in  the  organism,  has  been 
established  within  the  present  century.  The  knowledge  of  this 
all-important  part  of  the  medical  science,  in  past  centuries, 
was  very  imperfect  and  unreliable. 

It  was  perceived  that  in  order  to  make  these  sounds  audible 
and  distinct,  instruments  were  needed.  These  sounds  were 
too  weak  to  be  perceived  without  them.  Therefore,  the 
means  by  which  these  sounds  might  be  carried  to  the  ear  of 
the  observer  were  brought  into  requisition. 

The  first  instrument  of  this  kind  was  introduced  by 
Laenneck,  and  was  called  the  Stethoscope.  It  consisted  of  a 
wooden  cylinder  or  tube,  widened  at  each  end,  the  smaller  end 
of  which  was  applied  to  the  part  of  the  body  to  be  examined, 
whilst  the  ear  of  the  examiner  was  applied  to  the  other.  It 
was  called  Stethoscope,  because  it  was  believed  that  the  most 
important  sounds  were  produced  in  the  chest,  which  in  Greek 
is  called  Stethos. 

Further  progress  was  made  in  Auscultation.  Instead  of 
the  wooden  cylinder  other  instruments  of  different  material,  of 
greater  or  lesser  size  were  produced,  but  they  were  always 
called  Stethoscope,  and  they  were  intended  to  carry  the  sounds 
directly  to  one  ear  of  the  examiner. 


The  Phonendoscope  and  Its  Practical  Application. 


At  the  same  time  progress  was  made  in  the  scientific 
knowledge  of  percussion,  for  the  sounds  produced  by  percus- 
sion show  the  nature  of  the  interior,  as  modified  by  the  differ- 
ent layers  of  muscles  and  skin,  which  modify  the  sound, 
according  to  the  thickness  or  thinness  of  these  outer  walls. 

In  percussion  an  instrument  was  used  which  is  named  the 
percussion-hammer  The  hand,  or  the  Pleximeter,  were  used 
to  modify  the  sounds  produced  by  the  hammer.  This  instru- 
ment was  sometimes  round  and  flat,  sometimes  bi-convex,  or 
elliptic,  and  was  generally  made  of  wood  or  ivory. 

The  sounds  produced  in  this  manner  were  only  partially 
carried  to  the  ear,  because  a  good  deal  of  the  sound  thus  pro- 
duced was  lost  in  the  surrounding  atmosphere.  Weak  sounds, 
thus  produced,  could  hardly  be  perceived. 

An  improved  Stethoscope,  one  end  of  which  was  applied 
to  the  body,  with  two  tubes,  one  for  each  ear,  invented  by  the 
Americans,  Drs.  Camman  and  Clarke,  was  a  marked  advance, 
and  the  benefits  derived  from  it  were  greater  than  those  of  the 
first  instrument.  The  sounds  produced  by  percussion  were 
more  accurately  perceived. 

The  investigations  made  by  myself  by  means  of  the  Steth- 
oscope, which  consisted  of  two  pieces  of  wood  and  two 
tubes,  and  then  also  by  means  of  the  Microphone,  which  pro- 
duced sounds  still  more  accurately,  inspired  me  with  the 
thought  to  search  for  an  instrument  which  should  not  lose  the 
minor  sounds,  as  is  the  case  with  the  Stethoscope;  nor  exagger- 
ate them,  as  is  the  case,  when  the  Microphone  is  used,  and 
which  should  produce  the  natural  sounds  of  the  organism,  as 
well  as  the  artificial  ones,  which  are  produced  by  percussion, 
without  changing  the  pitch  of  any  and  each  particular  sound. 

An  esteemed  physicist,  Prof.  Eugene  Bazzi,  gave  his  con- 
sent, to  give  expression  to  this  thought,  which  had  originated 
in  my  mind,  and  was  willing  to  make  a  number  of  practical 
experiments,  and  thus,  an  instrument  or  apparatus  was  pro- 
duced which  possessed  all  the  desired  qualities,  not  only  for 
the  purpose  of  making  medical  examinations  and  investiga- 
tions, but  also  for  the  purpose  of  ascertaining  the  most  minute 
sounds  which  are  produced  by  living  bodies  of  whatever  sort, 
whether  the^e  sounds  be  natural  or  artificial. 


The  Phonendoscope  and  Its  Practical  Application.  n 

This  instrument  was  called  Phonendoscope  (i.  e.,  an  in- 
strument which  carries  to  the  outside  sounds  which  originate 
within  an  organism) ;  and  thus  it  came  to  pass  that  my  idea 
was  put  into  practice,  and  a  method  of  auscultation  and  per- 
cussion, the  slightest  effect  of  which  is  united  with  the  greatest 
simplicity,  and  by  means  of  the  intelligence  and  patient  labors 
of  the  thorough  physicist,  was  fully  realized. 

The  instruments  made  by  the  firm  of  Martin  Wallach,  Nach- 
folger,  in  Cassel  (sold  by  their  agents  in  America,  Geo.  P. 
Pilling  &  Son,  Philadelphia),  are  the  most  perfect.  It  is  about 
the  size  of  a  large  watch,  and  consists  of  a  metallic  box  with 
two  vibrating  plates,  by  means  of  which  the  instrument  is 
placed  upon  the  body  to  be  examined.  Two  gum  tubes  serve 
as  conductors  of  the  sound  from  the  body  to  the  ears.  In 
many  cases,  and  for  some  purposes,  one  tube  alone  suffices,  but 
the  other  must  also  be  attached  to  the  instrument.  By  means 
of  a  small  buttoned  rod,  which,  when  needed,  may  be  secured 
to  the  lower  vibrating  plate,  makes  it  possible  to  localize  the 
point  to  be  examined  by  auscultation,  i.  e.  the  point  to  be  ex- 
amined, with  the  instrument,  by  the  ear.  In  this  way  you 
are  enabled  to  perceive  the  sound-waves,  even  at  a  distance 
from  the  vibrating  body,  with  very  little  loss  of  sound,  and 
without  change  of  rhythm  or  intensity,  and  this  vibration  is  per- 
ceived with  single  or  double  sensibility,  according  to  the  wish 
of  the  examiner. 

The  Phonendoscope  does  not  produce  any  material  change 
in  the  observation  of  the  vibrations  of  the  body  examined,  but 
carries  the  sound  waves,  without  change  or  dispersion  to  the 
ears,  and  delivers  them  as  a  whole;  as,  for  instance,  murmurs, 
or  noises,  just  as  they  exist  in  the  locality  of  the  body  which 
is  being  examined,  in  their  absolute  perfection,  and  makes  it 
possible  for  us  to  perceive  the  same,  with  either  simple  or  dou- 
ble strength  and  sensibility,  as  we  may  be  inclined  to  use  either 
one  or  both  tubes,  which  carry  the  sound  to  the  ears. 

All  objections  which  might  be  advanced  as  regards  the 
exaggeration  of  sound,  or  changes  of  the  same,  or  abnormal 
sensitiveness,  etc.,  are  vain;  on  the  contrary,  the  Phonendo- 
scope surpasses  all  other  instruments  of  the  kind,  on  account 
of  the  small  volume,  as  well  as  by  its  peculiar  adaptability  for 


The  Phonendoscope  and  Its  Practical  Application. 


the  purpose  of  examining  any  and  all  sounds  produced  in  the 
body  to  be  examined.  No  other  instrument,  made  heretofore. 
can  be  compared  to  this,  which  surpasses  all  others  in  accuracy 
and  usefulness. 

The  practical  application  of  the  Phonendoscope  is  not  diffi- 
cult. If  it  is  intended  to  serve  for  the  auscultation  of  the 
internal  parts  of  the  body,  we  simply  lay  the  instrument  upon 
the  part  to  be  examined,  and  press  it  down  a  little,  and  accord- 
ing to  the  sensibility  and  effect  we  desire  to  produce,  we  sim- 
ply place  one  or  both  tubes  into  the  ear  or  ears.  But  if  the 
examination  is  to  be  made  upon  a  single  part,  and  upon  a  cir- 
cumscribed area,  then  all  that  is  required  is  to  screw  the  little 
buttoned  rod  into  the  lower  plate,  and  press  more  or  less 
strongly  upon  the  external  part  or  point.  Ultimately,  if  the 
Phonendoscope  is  to  be  applied  for  the  artificially  produced 
conditions,  which  may  be  induced  at  will,  then  the  buttoned 
rod  must  always  be  used.  In  most  of  these  cases  one  tube 
alone  suffices  for  auscultation. 

The  sounds  produced  by  the  percussion  hammer  on  the 
Pleximeter,  or  with  the  finger  upon  the  finger,  are,  under  the 
circumstances,  too  strong  for  the  Phonendoscope.  A  gentle 
rubbing  upon  the  surface  of  the  body  is  quite  sufficient.  A 
simple  rubbing  with  the  index  finger  about  the  point  to  be  ex- 
amined. One  rule  only  must  be  followed  in  order  to  become 
proficient  in  the  application  of  the  Phonendoscope.  When  you 
apply  the  instrument  see  to  it  that  the  body  and  the  tubes  do 
not  touch  anything,  and  do  not  rub  against  any  article  of  dress, 
nor  against  each  other,  for  such  rubbing  produces  sound,  which 
does  not  belong  to  the  area  to  be  examined.  This  precaution 
is  easily  taken. 

The  practical  auscultation  by  means  of  the  Phonendoscope, 
so  that  the  different  sounds  and  noises  in  the  bod}'  may  be  dis- 
tinctly observed,  is  easily  and  quickly  accomplished.  The 
ordinary  knowledge  furnished  us  by  Semiotics,  in  regard  to  the 
different  noises,  is  sufficient.  But,  on  the  other  hand,  great 
care  is  required,  in  auscultation  with  the  Phonendoscope,  when 
we  produce  artificial  sounds  in  the  body.  It  requires  some 
study,  although,  some  rules  have  been  obtained  in  Semiotics, 
according  to  which  we  must  measure  the  sounds  and  noises. 


The  Phonendoscope  and  Its  Practical  Application  13 


These  rules,  when  applied,  modulate  sound,  and  present  it  in  a 
higher  or  lower  pitch  ;  this  requires  special  care  and  attention. 

Several  gum  tubes,  more  or  less,  as  may  be  desired,  may 
be  attached  to  the  Phonendoscope ;  and  thus,  a  larger  or 
smaller  number  of  persons  may  listen  simultaneously,  and  the 
lecturer  may  speak  on  the  semiological  value  of  a  particular 
sound,  which  may  be  observed  by  all  who  listen  to  it  at 
once. 

Considered  from  this  standpoint  the  Phonendoscope  offers 
every  guarantee  for  the  correctness  of  the  results  of  an  exami- 
nation, inasmuch  as  several  experts  may  convince  themselves 
of  the  existing  condition,  at  one  and  the  same  time.  For  clin- 
ical instruction  this  instrument  enables  the  teacher  to  explain 
the  value  and  character  of  the  sounds  to  a  number  of  his 
hearers,  who  may  listen,  with  him,  while  he  analyzes  them. 
To  a  certain  extent,  the  sounds  may  be  weakened,  when  so 
many  listen  at  once  ;  but,  nevertheless,  the  sounds  artificially 
called  forth,  or  naturally  produced,  may  be  analyzed  with  cer- 
tainty, inasmuch  as  six  or  eight  persons  may  take  part  in  the 
examination,  all  of  whom  observe  the  same  sound,  at  the  same 
time,  and  thus  come  to  a  definite  conclusion,  in  regard  to  the 
sounds  which  they  hear.  If  there  is  a  difference  this  will  only 
depend  on  the  difference  in  the  organs  of  hearing  of  the  differ- 
ent observers. 

After  thus  enumerating  the  main  characteristics  of  Phonen- 
doscopical  examinations  we  now  come  to  its  practical  applica- 
tion in  the  practice  of  medicine. 

Its  uses  in  midwifery  and  gynaecology,  as  well  as  in  surg- 
ery, offer  themselves  as  objects  of  study  to  us,  at  this  time,  in 
this  branch  of  the  science,  and  it  appears  necessary  to  me  to 
make  my  investigations,  with  a  view  to  point  to,  and  apoly 
the  Phonendoscope  in  semiology,  more  especially  to  the  in- 
ternal parts,  in  relation  to  practical  treatment. 

If  you  place  the  Phonendoscope  with  one  of  its  vibrating 
plates  upon  a  living  body,  or  if  a  living  body  rests  upon  it 
wholly  or  in  part,  whilst  the  tubes  are  in  the  ears  of  the  exam- 
iner, he  will  notice  a  rhythmical  sound,  of  greater  or  lesser  in- 
tensity, and  equality,  which  is  continued  as  long  as  the  instru- 
ment is  in  contact  with  the  living  body. 


14  The  Phonendoscope  and  Its  Practical  Application 


This  noise,  which  originates  in  the  vascular  system,  and 
in  the  muscular  walls,  is  of  different  intensity,  as  is  self-evi- 
dent, and  is  in  close  relation  with  the  circulation  of  the  blood, 
and  the  blood  pressure,  more  or  less  ;  and,  on  the  other  hand, 
also  results  from  the  condition  of  the  muscles,  at  the  point  of 
investigation . 

This  noise  was  called  Dermatophony,  and  could  only  be 
proved  thus  far,  with  the  very  sensible  Microphone,  which, 
owing  to  the  peculiar  construction  of  the  parts,  was  not  easily 
transportable. 

If  you  place  the  Phonendoscope  over  a  joint,  or  on  the 
ending  of  a  muscle,  and  then  make  a  movement  of  the  joint  or 
muscle,  or  if  you  pass  a  steady  (constant)  or  an  inductive  cur- 
rent through  them,  then  the  exaltations  or  actions,  in  all 
their  variations  and  distinctions  are  perceived  by  the  Phonen- 
doscope, and  the  instrument,  in  this  way,  reveals  the  normal  or 
abnormal  condition  of  the  parts  examined.  The  same  is  true 
of  a  bone  that  may  be  broken,  or  which  is  believed  to  have 
been  broken.  If  you  place  the  instrument  upon  that  part,  then 
if  there  is  a  fracture,  the  least  movement  of  the  fractured  parts 
will  reveal  the  grating  noise  of  the  fractured  bones,  which  will 
be  distinctly  audible.  The  injured  man  does  not  suffer  any 
pain,  from  this  procedure. 

The  auscultation  of  the  tones  of  the  sounds  and  noises  ttut 
are  caused  by  the  exaltation  of  the  respiration  is  easily  accom- 
plished, and  distinctly  perceived,  with  the  Phonendoscope. 
This  is  done  by  placing  one  plate  of  the  instrument  upon  the 
breast,  and  by  pressing  it  gently  against  the  chest- wall.  The 
surface  of  about  six  inches  is  thus  examined,  and  the  condition 
of  the  lungs,  may,  by  examination,  be  revealed,  in  a  very 
short  time. 

In  order  to  examine  the  sounds  accurately  in  different 
parts,  upon  which  the  plate  of  the  Phonendoscope  cannot  be 
laid,  all  that  is  necessary  is  to  touch  the  parts  with  the  little 
buttoned  rod.  By  means  of  this  rod  the  given  tones  of  the 
lungs  can  be  ausculted,  whether  it  be  the  apexes,  or  parti- 
tions on  the  sides.  This  may  be  done  by  listening  with  one 
or  both  ears,  according  as  it  may  appear  best,  and  according 
to  the  sounds  produced  inside,  whether  they  be  stronger  or 


The  Phonendoscope  and  Its  Practical  Application. 


weaker.  Thus  respiration  in  all  its  peculiarities  may  be  accur- 
ately analyzed.  The  least  abnormal  phenomena,  which  show 
themselves,  will  be  perceived.  Just  on  this  very  account  the 
Phonendoscope  possesses  an  undisputed  superiority  over  all 
other  means  employed  for  auscultation. 

When  we  auscult  the  larynx  or  trachea  we  hear  clearly 
the  acoustic  manifestations,  which,  by  the  passage  of  the  air 
through  these  organs,  are  called  into  existence,  and  the  local- 
ity may  be  accurately  pointed  out,  where  modifications  caused 
by  roughness,  sthenosis,  etc.,  exist. 

We  now  pass  on  to  the  auscultation  of  the  acoustic 
manifestations  of  the  circulation  of  the  blood,  and  the  sounds 
produced  by  the  blood-wave,  and  those  which  are  heard  in  the 
larger  blood  vessels,  and  also  those  which  originate  in  the 
heart  ;  i  e.,  noises  which  can  be  distinguished  from  each  other 
by  their  peculiarities.  This  kind  of  auscultation  may  be  accom- 
plished either  with  the  plate,  or  with  the  little  rod  ;  this  last 
especially,  for  the  purpose  of  those  tones,  i.  c  ,  those  points, 
where  the  heart  sounds  are  most  clearly  and  distinctly  per- 
ceived, or  heard. 

Not  only  the  points  of  the  strongest  intensity  of  sounds, 
which  are  produced  by  the  valves  of  the  heart,  but  also  the 
diffusive  sounds  may  be  fixed,  as  well  as  the  point  where  these 
sounds,  produced  by  this  central  cause,  have  their  stopping 
place,  or  where  the  sounds  of  another  neighboring  central 
point  become  more  distinctly  audible.  In  this  way  then,  we 
are  enabled,  with  the  greatest  facility,  to  make  a  diagnosis  of 
the  condition  of  the  heart  and  its  action  in  general,  and  the 
peculiar  action  and  condition  of  its  parts  in  particular. 

Here  you  will  permit  me  to  make  a  few  observations  on 
the  new  art  now  made  possible  of  examining  with  the  Pho- 
nendoscope, namely,  about  comparative  auscultation. 

This  examination  is  rather  more  of  a  clinical  than  practi- 
cal nature,  not  onl}r  for  the  purpose  of  instruction  in  the  class- 
room, but  for  its  manifold  usefulness  in  the  actual  practice  of 
the  physician. 

For  the  purpose  of  comparative  auscultation  two  instru- 
ments are  requisite,  which  must  be  placed  on  the  two  different 
points  which  are  to  be  examined  and  compared.  One  tube  of 


1 6  The  Pkonendoscope  and  Us  Practical  Application. 


each  instrument  must  be  placed  in  the  ears.  In  this  way  we 
accomplish  the  conveying  of  the  sounds  of  the  two  points  which 
are  to  be  examined  at  once,  in  order  that  the  sounds  produced 
in  each  may  be  compared  with  each  other,  and  the  sound-wave 
is  to  be  interrupted  by  taking  now  one  and  then  the  other  tube 
into  the  ear  and  out  of  it,  or  the  tubes  maybe  compressed  alter- 
nately, and  the  sound  stopped  now  in  one  and  then  in  the 
other.  In  this  way  the  sounds  and  noises  of  the  different 
points  may  be  differentiated  and  compared  most  accurately. 

In  this  way,  too,  may  be  heard  at  one  and  the  same  time, 
the  workings  of  both  lungs,  in  one  and  the  same  individual,  or 
those  of  certain  different  parts,  in  the  lungs  of  the  patient,  and 
the  corresponding  part  of  one  who  is  perfectly  well,  and  in  his 
normal  condition. 

The  same  comparative  auscultation  may  be  instituted  on 
the  heart  of  two  individuals,  a  sick  man,  and  one  who  is  well. 
Heretofore  this  new  method  of  investigation  has  not  been  pos- 
sible for  want  of  a  suitable  instrument,  but  now,  this  can  be 
easily  accomplished  without  any  trouble.  This  new  method 
may  be  applied  to  many  other  parts. 

To  come  back  to  the  use  of  the  Phonendoscope  in  simple 
auscultation,  we  may  see  its  usefulness  in  the  examination  of 
the  lower  parts  of  the  abdomen,  which  heretofore  has  been  but 
seldom  or  not  at  all  applied  to  these  parts.  The  question  here 
is  not  as  to  the  murmuring  noises  only,  as  is  the  case  when  we 
examine  the  heart  and  lungs,  but  also  the  noises  which  we  hear 
when  we  examine  the  stomach  and  the  liver,  and,  in  some 
cases,  in  superfluous  meteorism,  or  by  too  much  liquid  being 
deposited  or  lodged  in  the  lower  parts  of  the  abdomen,  but  also 
those  sounds  which  are  of  a  local  character,  and  which  are 
caused  by  pathological  or  physiological  conditions.  All 
acoustic  manifestations  which  originate  in  the  stomach  and 
intestines,  as  likewise  the  process  of  digestion,  which  is  going 
on  in  these  organs,  may  be  observed  by  the  physician,  by  means 
of  this  instrument. 

This  is  an  entirely  new  semiotic,  which  by  study  and  prac- 
tice offers  many  advantages.  But  the  variation  of  sounds 
which  we  perceive  by  this  method  of  examination  is  truly 
astonishing.  You  may  notice  the  absolute  silence  that  is  but 


7 he  Phonendoscope  and  Its  Practical  Application.  17 


seldom  interrupted  in  cases  of  inactivity  and  paralysis  of  the 
muscular  coating  of  the  stomach  and  intestinal  tube.  You 
may  hear  a  noise,  as  if  grating  or  grinding  to  and  fro,  of  dif- 
ferent strength,  according  to  the  rapidity  with  which  the  con- 
tents of  these  organs  are  moving  onward.  Much  depends 
upon  the  nature  of  these  contents,  whether  they  be  of  a  gatey 
or  of  a  liquid  character,  and  whether  they  are  mixing  under 
the  muscular  process  of  the  intestines  ;  thus,  you  hear  the 
gurgling  sound  in  the  bowels,  when  the  existing  gas  escapes 
from  a  narrow  into  a  wider  passage,  through  liquid  substance, 
and  moves  either  forward  or  backward,  or  up  and  down.  You 
hear  the  dull,  but  at  the  same  time  rhythmical  sound  earned  by 
the  exertions  which  are  used  by  the  stomach  as  it  discharges  its 
contents  through  the  pyloric  orifice  into  the  duodenum. 

In  some  cases  of  tuberculosis  of  the  omentum  or  peri- 
tonium,  or  of  peritonitis,  when  the  dry  rubbing  sounds  of  the 
surfaces  against  each  other  are  distinctly  audible,  whilst  the 
sounds  produced  by  hydatic  cysts,  as  those  produced  by  the 
peristaltic  movements  of  the  mucous  membrane  of  the  bowels, 
are  distinctly  perceptible. 

I  will  not  speak  of  the  Phonendoscopic  auscultation  of  the 
brain,  in  order  that  I  may  have  more  time  to  explain  the  arti- 
ficially produced  exaltation  of  the  organs,  which  are  to  be  ex- 
amined with  the  Phonendoscope.  In  this  way  we  are  enabled 
to  give  accurately  the  form,  the  location,  and  the  relations  of 
those  organs,  whilst  this  method  of  examination  enables  us  to 
find  out  their  tonicity  and  density. 

By  this  examination  the  little  rod  of  the  Phonendoscope  is 
applied  to  a  point,  which  has  been  made  bare  by  the  removal 
of  all  clothing,  and  which  is  pressed  firmly  upon  the  skin, 
whilst,  for  the  most  part,  the  use  of  one  ear  tube  suffices.  It 
is  sufficient  if  you  rub  with  the  index  finger  over  the  surface 
in  the  neighborhood  of  the  little  rod,  which  will  produce  some 
little  vibration  in  the  parts,  which  may  be  distinctly  heard, 
which  differs,  however,  according  to  the  density  and  tonicity 
of  the  organ  which  is  being  examined.  After  this  you  rub  in 
the  same  manner,  at  some  little  distance  from  the  first  spot.  If 
you  can  produce  no  sound  or  but  little,  then  you  continue  to 
rub  toward  the  button  of  the  little  rod,  and  with  a  pencil  mark 


i8  The  Phonendoscope  and  Its  Practical  Application. 


the  place,  where  the  vibration  takes  place,  and  is  similar  to  the 
vibration  excited  in  the  region  of  the  buttoned  rod.  If  you 
continue  to  make  a  circular  motion  about  the  rod,  by  carefully 
rubbing  from  circumference  towards  the  central  point,  and  in 
doubtful  cases,  from  the  little  rod  towards  the  outer  circle,  then 
you  will  be  enabled  to  fix  a  number  of  points,  which  will 
reveal  the  condition  of  the  internal  organs,  within  this  certain 
radius  that  has  been  examined. 

A  few  rules  are  to  be  observed,  and  are  easily  understood 
and  followed. 

It  is  better  to  let  the  buttoned  rod  rest  upon  the  soft  parts, 
and  not  upon  any  bone,  because  in  the  latter  case,  the  vibra- 
tions or  sounds  of  the  organs  will  be  similar  to  that  which  is 
heard  in  the  bone,  and  thus  might  be  mistaken,  and  greater 
care  is  required  to  differentiate  where  the  vibration  or  sound  of 
each  organ  stops,  or  where  that  which  originates  in  the  bone 
does  not  continue  to  go  on. 

It  is  further  to  be  observed  that  by  too  much  pressure,  with 
the  buttoned  rod  upon  the  surface,  the  sound  or  vibration  pro- 
duced there  may  suppress  that  of  the  internal  organs,  and  even 
the  vibration  of  the  skin  itself  will  be  partially  weakened  by 
too  much  pressure.  This  possible  cause  for  error  must  there- 
fore be  avoided. 

It  is  necessary  that  the  buttoned  rod  shall  rest  upon  one 
part  of  the  internal  organ  which  is  not  covered  by  any  other 
organ,  otherwise  it  will  be  impossible  to  fix  the  point  within 
the  circumference,  with  any  degree  of  accuracy.  For  example, 
when  the  heart  is  being  examined,  with  the  Phonendoscope, 
then  the  rod  must  be  placed  over  the  heart,  where  the  heart  is 
free,  and  not  overlapped  by  the  tips  of  the  lungs,  but  in  the 
mediastinum,  or  place  where  the  heart  lies  nearest  to  the  chest- 
wall.  When  we  examine  the  stomach,  then,  only  those  parts  are 
to  be  chosen,  which  are  not  covered  by  the  left  tip  of  the  liver. 

It  is  also  necessary  to  place  the  little  rod  over  various 
selected  points  of  different  organs,  in  order  to  ascertain  the  size 
and  place  of  these  organs.  For  example,  for  the  examination 
of  the  heart  the  little  rod  must  be  placed  within  the  fourth 
intercostal  space  near  -the  sternum,  and  for  the  liver  in  the 
seventh  intercostal  space  upon  the  nipple  of  the  right  breast; 


«*•  P.  s.  o-REILLy  a  STAFp 

1 'he  Phonendoscope  and  Its  Practical  Application.  19 

for  the  stomach  likewise  in  the  seventh  intercostal  space,  but 
placed  on  the  left  nipple. 

If  an  organ  happens  to  be  very  much  enlarged,  then  the 
rod  must  be  placed  over  it  in  several  points  successively.  As 
e.  g .  for  the  liver  first  in  the  seventh  intercostal  space  on  the 
right  nipple,  then  in  the  ninth  under  the  axilla,  and  in  the 
sword-like  continuation  of  the  twelfth  joint  of  the  spinal 
column. 

For  the  stomach,  the  rod  is  first  placed  in  the  seventh  in- 
tercostal space  upon  the  left  nipple,  then  on  the  linia  alba  near 
the  curve  of  the  short  ribs. 

If  an  organ  is  divided  into  several  parts  of  segments,  like 
the  lungs',  divided  by  a  middle  wall,  and  space  for  the  heart,  or 
is  separated  by  ligaments,  like  the  hepatic  bands,  or  if  an  organ 
contains  substances  of  different  consistency,  as  the  stomach, 
containing  both  gas  and  food,  then  the  little  rod  must  be  placed 
at  different  points  successively,  because  these  organs,  as  a 
whole,  are  divided  into  parts,  which  are  separated  by  spaces, 
ligaments  and  substances  of  different  thicknesses,  which  hinder 
'the  sounds  from  passing  through  the  whole  organ  at  once,  and 
at  the  same  time. 

If  we  proceed  in  this  way,  and  by  the  method  marked  out 
above,  then,  truly,  the  results  are  most  convincing  and  astonish- 
ing. There  are  certain  points  which  may  be  fixed  in  a  given 
locality;  the  parts  of  the  lungs  in  their  two  sides;  the  Nivean 
of  the  liquid  contents  of  the  pleura  and  abdominal  cavity,  the 
contour  and  outline  of  the  stomach,  together  with  the  shifting 
of  the  contents,  according  to  the  position  in  which  the  patient 
may  happen  to  lie;  so  with  the  chambers  of  the  heart,  and  the 
flaps  or  lobes  of  the  liver,  etc,  etc. 

If  any  organ  is  to  be  examined  which  is  covered  by  some 
other,  but  elastic  organ,  which  weakens  the  sounds,  then  the 
rubbing  with  the  finger  over  the  skin  must  be  conducted  with 
more  force.  For  example: — in  case  of  an  emphyscmatous 
lung,  which  may  overlap  the  heart  we  must  rub  with  more 
force,  than  would  be  required  in  that  locality,  where  the  heart 
lies  in  more  direct  contact  with  the  chest-wall. 

By  means  of  this  method  of  investigation  we  are  enabled 
to  draw  the  size  of  the  organ  upon  the  skin,  as  accurately  as  if 


20  The  Phonendoscope  and  Us  Practical  Application. 


we  could  place  their  shadow  there,  with  this  exception,  that 
the  shadow  forms  a  visible  spot,  whereas,  in  this  way,  thepho- 
nentical  shadow  may  be  drawn  whole,  and  in  all  its  parts  and 
subdivisions,  into  which  these  organs  may  happen  to  be  divided, 
by  walls  and  furrows. 

These  results  had  already  been  obtained  with  the  double 
Stethoscope;  and  my  observations  made  since  1882,  which  I  have 
published,  are  confirming  them.  But  by  means  of  the  Phonen- 
doscope we  can  examine  with  greater  accuracy,  and  far  less 
trouble,  and  without  loss  of  time. 

(The  speaker  here  referred  to  the  successful  examinations, 
each  by  itself,  of  the  different  organs,  as  the  lungs,  heart, 
stomach,  liver, duodenum,  bladder, spleen,  kidneys,  and  especial- 
ly referred  to  Prof.  A.  Bianchi's  intention  to  give  further  in- 
struction in  the  future,  on  the  use  of  the  Phonendoscope). 

As  you  see,  the  plans  and  drawings  mark  out  the  size  of 
the  organs  most  accurately.  The  plans  and  drawings  of  the 
different  organs  may  be  made  without  loss  of  time.  They 
mark  the  location  of  each  organ,  and  their  relations  one  to 
another.  Thus  we  may  observe  how  far  the  lobes  of  the  lung 
overlap  the  heart.  You  may  observe  how  far  the  liver  elevates 
the  diaphragm  and  the  degree  or  extent  to  which  the  pyloris  is 
covered  by  the  liver.  We  may  fix  the  extent  of  the  cardia  of 
the  stomach,  and  you  can  study  the  curves  of  the  colon  and  of 
the  stomach  as  well. 

Not  only  this:  We  may  study  displacements  and  changes 
in  the  structure,  and,  by  means  of  this  method,  we  may  outline, 
by  drawings,  these  very  changes,  and  thus  place  them  in  reality 
before  our  very  eyes. 

For  this  purpose  the  organs  are  first  drawn,  whilst  the 
patient  is  lying  on  his  back,  then  he  is  to  get  up  quickly,  and 
stand  upon  his  feet;  or  he  may  be  first  ordered  to  lie  on  his 
right,  then  on  his  left  side,  and  thus  we  are  enabled  to  fix  with 
certainty,  the  location  of  the  different  organs,  in  the  different 
positions  of  the  patient. 

Finally,  even  the  shifting  of  the  organs,  from  place  to 
place,  may  also  be  observed,  as  caused  by  the  different  functions 
which  they  perform;  thus  for  example,  whilst  we  cause  the 
patient  to  take  a  deep  inspiration,  we  may  not  only  observe  how 


The  Phonendoscope  and  Its  Practical  Application. 


far  his  lungs   expand,   but  also  what  motions  they  impart  to 
other  neighboring  organs. 

These  few  short  examples  show  how  far  the  use  of  the 
Phonendoscope  may  be  carried  in  medical  practice.  Many 
examinations  which  heretofore  were  most  difficult  to  make, 
and  those  which  could  only  be  made  in  part, and  very  imperfectly, 
can  now,  by  the  aid  of  this  instrument,  be  made  with  the 
greatest  certainty  and  facility. 

(The  experiments  which  were  made  during  the  lecture  in 
the  presence  of  many  physicians,  were  absolutely  satisfactory, 
and  Professors  Rossoni,  Queirolo,  and  Felice,  confirmed  the 
usefulness,  and  the  advantages  which  they  had  derived  from 
the  use  of  the  Phonendoscope,  in  their  clinical  examinations. 


CHAPTER  II. 


PHONENDOSCOPY  OF  THE  ORGANS,  ESPECIALLY 
CONCERNING  THE  STOMACH  AND  ITS  CON- 
TENTS, WITH  EXPERIMENTS. 

The  method  of  examining  with  the  Phonendoscope,  or, 
as  it  is  now  called,  "  Phonendoscopy, "  differs  as  much 
from  the  ordinary  method  of  auscultation  and  percussion,  as 
differ  the  various  other  instruments  that  are  used  for  that  pur- 
pose from  the  Phonendoscope.  By  this  method  the  vibrations 
which  originate  in  the  organism,  while  performing  its  various 
functions,  or  those  which  are  called  into  existence  by  external 
influences,  are  carried  directly,  and  without  dispersion  or 
change,  to  the  ear  of  the  examiner.  And  it  is  on  this  account 
that  I  make  the  positive  assertion,  that  the  Phonendoscope  is 
superior  to  all  other  instruments  in  use  at  the  present  day.  It 
alone  reveals  the  exact  condition  of  things  as  they  exist  in  the 
organism.  Neither  the  Stethoscope  not  the  old  percussion 
method  could  make  audible  sounds  with  anything  like  the  same 
degree  of  accuracy.  I  have  repeatedly  referred  to  its  value 
and  uses,  when  employed  in  exploring  the  internal  parts,  since 
my  first  invention  and  use  of  the  instrument  in  1894. 

(i)  At  that  time  I  used  an  ordinary  Stethoscope  to  which 
I  attached  more  rubber  tubes,  with  olives  for  the  ears.  I  also 
devised  another  Stethoscope,  in  the  form  of  a  little  bell,  to 
which  I  fastened  the  tubes  directly.  (2)  This  instrument  had 
enabled  me  to  obtain  important  results,  but  it  does  not  possess 
the  accuracy  and  importance  of  the  Phonendoscope.  It  is 
only  since  I  had  this  perfect  instrument  that  I  could  get  abso- 
lutely new  results,  and  could  state,  with  the  greatest  accuracy, 
the  most  minute  modifications  in  the  formation  of  the  various 
organs. 


(1)  Dell  auscultazione  stetoscopica  della  percussione,  kirista  cliiiica,  Bologna  &  Gaz. 

ospedali,  Milano,  1884.     Riforma  medica,  Napoli,  1885. 

(2)  Italian  edition  of  the  "  Semiologie,"  by  Eichhorst,  vol.  i,  1885. 


Phonendoscopy  of  the  Organs. 


Bedersky  in  Kiew,  (3)  and  Aufrecht  in  Magdeburg,  have 
one  after  the  other  tried  to  use  an  instrument  in  the  form  of  a 
bell  similar  to  the  one  described  by  me  since  1884,  but  the 
results  obtained  by  them  were  not  any  better  than  mine,  by  the 
same  identical  instrument.  The  fact  is  that  the  Stethoscopes  of 
Bedersky  and  Aufrecht  have  air  chambers  which  are  too  large, 
and  the  vibrations  become  dispersed  instead  of  concentrated. 
They  are  without  the  vibrating  plate,  and,  therefore,  cannot  be 
used  on  an  extensive  surface  with  the  same  ease  as  on  a  surface 
of  limited  extent.  Their  instruments  enable  us  to  examine  but 
a  limited  surface,  and  cannot  be  altered  so  as  to  meet  the  require- 
ments of  the  examination. 

Charles  Verdin,  of  Paris,  has  expressed  the  opinion,  ( 4;  after 
an  accurate  study  of  the  Phonendoscope,  that  before  this  no 
similar  instrument  was  in  existence,  and  that  all  others  which 
were  produced  in  imitation  of  the  same  could  not  give  the 
same  results  as  the  Phonendoscope,  except  those  instruments 
which  were  correct  copies  of  the  original. 

In  a  critical  study  (5)  of  the  question  concerning  this 
subject  I  have  tried  to  point  out  this  fact  most  clearly,  in  the 
history  of  the  instrument. 

The  commission  nominated,  with  this  end  in  view,  by  the 
"  Societe'  de  Medicine"  at  Paris,  (6)  fully  recognized  the 
novelty  and  priority  of  the  instrument,  as  well  as  the  novelty 
of  the  method. 

I. 

The  results  which  can  be  obtained  by  an  examination  with 
the  Phonendoscope  are  very  many,  but  they  can  be  divided  into 
two  main  sections  : — 

First : — They  enable  us  to  hear  the  sounds  produced  by 
the  functions  of  the  organs. 

Second — They  enable  us  also  to  hear  the  sounds  which  are 
produced  artificially.  As  every  sound  is  caused  by  vibration, 


(3)  Academic  de  Medicine,  Paris,  1896. 

(4)  Aertze-Verein,  Berlin,  1897 

(5)  Die  Vorlanfer,  Nachahamer  &  Abanderer  des  Phonendoscops,  Cassel,  1897. 

(6)  lectures  of  the  Societe  de  Medicine,  Paris,  March,  1896. 


24  Phonendoscopy  of  the  Organs. 

it  is  certain,  that  with  the  Phonendoscope,  we  can  make  audi- 
ble the  vibrations  of  bodies  in  general,  and  of  the  human  body 
in  particular,  i.e.,  those  sounds  which  are  caused  by  the 
normal  or  pathological  functions  of  the  body,  as  well  as  those 
vibrations  which  are  caused  artificially,  in  the  organism,  by  any 
external  means.  For  this  reason  it  is  sufficient,  for  instance, 
to  pass  the  finger,  with  gentle  pressure,  over  the  surface  of  the 
bod}r,  or  to  observe  the  vibrations  transmitted  from  a  vibrating 
object,  such  as  a  tuning  fork  or  vibrating  rod. 

I  will  not  speak  to  you  at  this  time  about  the  first  part 
which  covers  almost  the  entire  field  of  auscultation.  With  the 
Phonendoscope  you  receive  better  and  more  accurate  results, 
but  the  laws  of  this  method  do  not  differ  from  those  of  the  ordi- 
nary auscultation. 

Here  I  wish  to  remark  that  the  doubts  expressed  by  some 
(Egger  and  Grote)  in  regard  to  the  modifications,  the  altera- 
tions and  the  deformity  noticed  in  the  sounds  obtained  by 
means  of  the  Phonendoscope  are  without  foundation.  In  these 
cases  we  have  always  to  do  with  investigations  and  experi- 
ments, the  technicality  of  the  instrument  not  having  been  under- 
stood well  enough,  or  with  the  faulty  application  of  the  instru- 
ment itself  to  the  parts  examined. 

To  obtain  perfect  results  it  requires  rather  strong  pressure, 
with  the  lower  surface  of  the  Phonendoscope,  or  the  little  rod 
attached  to  it,  according  as  we  desire  to  examine  a  large,  or  a 
limited  surface,  otherwise  the  vibrations  will  become  modified, 
and  imperfect,  and  weakened,  while  passing  through  the  dif- 
ferent layers  of  varying  thickness,  i.e.  muscles,  skin,  fatty 
tissue,  bones,  etc. 

With  a  gradually  increasing,  rather  strong  pressure,  we 
bring  the  different  layers  close  to  each  other,  and  in  this  way 
we  produce  an  almost  even  and  dense  mass.  By  means  of  this 
procedure  the  vibrations  are  well  conducted  through  the  artifi- 
cially produced  layer,  and  suffer  only  slight  modifications  and 
weakenings. 

With  this  end  in  view  we  can  make  an  experiment,  as  a 
limited  auscultation  of  the  sounds  of  the  heart,  at  the  point  Of 
this  organ.  When  the  Phonendoscope  is  simply  placed  upon 
the  skin  you  will  hear  almost  nothing,  especially  when  the 


Phonendoscopy  of  the  Organs.  25 


sounds  are  weak,  and  the  tissues,  lying  above  it,  are  very  thick. 
By  using  pressure,  you  will  hear  better  the  more  you  increase 
it,  but  only  up  to  a  certain  point,  and  then  it  will  be  the  reverse  ; 
for  too  much  pressure  will,  eventually,  to  a  certain  extent, 
smother  the  vibrations  of  the  organ  which  is  being  examined. 

II. 

The  most  important  and  useful  application  of  the  Phonen- 
doscope  consists  in  making  the  artificially  produced  sounds 
audible  for  the  purpose  of  ascertaining  the  formation  and  out- 
line of  the  different  parts  of  the  body.  The  possibility  of  out- 
lining the  organs  by  auscultation  in  connection  with  percussion 
was  mentioned  by  many  of  the  older  physicians  and  among 
these  were  Piorry  and  L,aenneck.  A  practical  application  was 
made  in  1841  by  the  two  Americans,  Cam  man  and  Clarke. 
Their  method  of  examining  simply  consisted  in  collecting  the 
vibrations  produced  by  a  double  stick  of  wood,  and  by  another 
physician  who  used  percussion.  But  this  method  was  not  of 
any  practical  importance  because  two  physicians  were  required 
when  it  was  applied,  the  one  to  auscult  and  the  other  to  per- 
cuss; later  on  this  method  was  partly  employed  by  Barthey, 
Roger,  Frederick  McBride,  Ewald  and  others,  and  for  the  rea- 
son mentioned,  in  but  isolated  cases. 

In  1880  I  again  took  up  this  method  of  examining  with  a 
double  Stethoscope  and  made  close  observations  and  investiga- 
tions, and  found,  after  many  trials  and  experiments,  the  laws  by 
which  I  could  apply  it,  as  a  real  semiologic  method,  which  may 
be  applied  in  all  cases  of  examinations  of  any  part  of  the  body, 
and  to  which  I  gave  the  name  of  "Stethoscopy,"  or  the  science 
of  making  audible  the  sounds  produced  by  percussion.  But 
the  inconvenience  of  requiring  an  assistant  to  hold  the  instru- 
ment in  its  place  was  still  there,  while  the  other  physician 
made  the  percussion,  and  auscultation.  The  writings  produced 
in  the  line  of  these  studies  are  rather  length y,  and  I  think  it 
advisable  to  quote  largely  for  the  convenience  of  those  who, 
perhaps,  would  like  to  make  some  experiments  of  this  kind. 

I  continued  my  examinations  by  this  method,  and,  in  the 
meantime,  I  hunted  for  an  instrument  which  should  allow  the 


a6  Phonendoscopy  of  the  Organs. 


physician  to  auscult  at  the  same  time  while  he  himself  produced 
the  vibrations  of  the  organs. 

In  1894  I  gained  the  conviction,  with  the  help  of  Dr. 
Bazzi,  Professor  of  Physic  in  Florence,  that  I  had  found  the 
right  method.  By  a  great  number  of  experiments  we  tried  to 
make  the  instrument  practical  and  suitable  for  all  cases  that 
might  occur,  and  finally  we  produced  such  a  one,  and  named 
it  the  "Phonendoscope"  (ascertainer  of  the  sounds  in  the 
interior  parts  of  the  body).  This  was  in  1894,  at  the  time  when 
the  Eleventh  International  Medical  Congress  met  at  Rome,  in 
Italy. 

The  Phonendoscope  made  by  Martin  Wallach,  Successor, 
in  Cassel,  Charles  Verdin,  in  Paris,  and  George  P.  Pilling  & 
Son,  Philadelphia,  U.  S.  A.  was  the  most  perfect,  and  other 
imitations  and  modifications  which  have  appeared  since  were 
always  inferior  to  the  original  instrument.  The  results  of 
which  we  have  spoken  were  obtained  only  by  using  the 
Phonendoscope  made  by  the  above-mentioned  firms,  and  no 
other. 

This  period  really  marks  the  commencement  of  the  study 
of  the  different  parts  of  the  body  by  means  of  artificially  pro- 
duced vibrations.  In  fact,  in  the  Phonendoscope  we  have  an 
instrument  which  makes  it  possible  for  us  to  examine  the  most 
minute  point,  or  any  part  of  the  body,  or  limitedarea,  and  also 
the  advantage,  that  by  means  of  it  every  physician  can  practice 
auscultation  with  the  greatest  of  ease,  while  he  himself  may 
produce  artificial  vibrations  in  the  part  which  he  examines.  It 
is  safe  to  say  that  this  method  has  its  real  origin  in  the  inven- 
tion of  the  instrument,  and  for  this  reason  I  named  it  the 
4 '  Phonendoscope. ' ' 

III. 

The  phonendoscopy  of  the  vibrations  which  we  may  wish 
to  produce  artificially  is  very  simple.  If  you  see  it  once  ap- 
plied you  will  be  able  to  follow  this  method  perfectly,  without 
any  trouble.  All  you  require  is  a  little  application  and  the 
necessary  practice.  It  has  many  advantages  over  the  ordinary 
method  of  percussion,  as  it  does  not  require  lengthy  experi- 
ments and  but  little  practice.  The  experts  in  percussion  are 


Phonendoscopy  of  the  Organs.  17 

very  few  and  scarce,  but  this  method  not  only  recommends 
itself  for  its  facility  of  learning  it  but  also  for  the  simplicity  of 
the  means  employed.  It  is  sufficient  to  pass  the  point  of  the 
finger  with  gentle  pressure  along  the  line  over  the  edge  of  the 
organ  to  be  examined,  to  produce  the  vibrations  necessary  for 
the  examination.  In  this  way  the  physician  does  not  become 
fatigued  from  percussion,  and  the  persons  nearby,  who  are 
otherwise  engaged,  are  not  di-turbed  by  the  sounds,  and  the 
individual  under  examination  does  not  feel  any  disagreeable  or 
painful  sensation.  Those  who  imagine  that  this  method  has 
the  same  limits  as  the  ordinary  percussion  method  are  simply 
mistaken;  for  there  are  certain  well-marked  differences  between 
both  methods. 

With  the  ordinary  percussion  method  you  cannot  dis- 
tinguish the  separation  which  marks  the  lobes  of  the  lungs,  nor 
those  of  the  heart,  neither  the  two  of  the  liver,  nor  can  you 
distinguish  the  changes  of  the  contents  of  the  stomach,  nor  the 
cardiac  or  piloric  end,  sometimes  not  even  the  lower  curve  of 
the  stomach,  nor  the  posterior  part  of  the  spleen;  also  very 
often  not  the  kidneys,  nor  the  organs  that  are  found  in  a  liquid 
state,  neither  can  you  find  the  limits  of  the  bones  and  the  ends 
of  the  muscles,  nor  the  fractures  of  bones.  In  one  word,  the 
results  of  phonendoscopy  differ  so  much  from  those  of  the 
ordinary  percussion  method,  that  nobody  would  compare  the 
one  with  the  other.  This  proves  that  phonendoscopy  is  the 
scientific  method  of  examining  the  form,  extention,  position, 
the  changes  and  the  respective  relations  of  the  parts  of  the  body, 
which  is  founded  upon  the  observation  of  sounds  with  the  ear, 
made  possible  by  the  use  of  the  Phonendoscope.  The  sounds 
observed  are  those  which  are  produced  by  the  vibrations,  as 
much  as  possible,  directly  transmitted  to  the  organ  of  a  body 
we  examine,  being  itself  in  vibrating  motion,  or  of  one  produc- 
ing such. 

You  can  see  what  a  large  field  for  investigation  has  thus 
been  opened  by  the  Phonendoscope,  and  so  various  in  its  use 
and  applications,  in  the  different  departments  of  medicine  and 
the  natural  sciences.  Through  the  co-operation  of  scientific 
thinkers  and  workers  the  highest  results  will  be  obtained  by 
this  method  which  it  is  possible  to  attain. 


28  Phonendoscopy  of  the  Organs. 

IV. 

The  theory  is  very  simple.  The  body  in  which  the  vibra- 
tions are  produced  must  transmit  the  same  to  the  ear  directly, 
more  or  less  in  their  totality.  To  obtain  these  results  three 
stages  are  necessary  in  the  examinations: 

First — That  of  producing  vibrations, 
Second — Transmitting  the  vibrations, 
Third—  That  of  noticing  the  vibrations. 

(1)  That  stage  producing  of  vibrations  is  caused  by  simply 
passing  over  the  part  or  parts  with  the  tip  of  the  finger.     The 
finger  must  be  well  pressed  upon  the  part  lying  over  the  organ, 
and  it  is  necessary  to  produce  in  the  different  layers  the  same 
degree  of  density,  whether  these  layers  be  in  direct  or  indirect 
contact  with  the  different  points  of  the  organ  to  be  examined 
or  not.  Therefore,  the  pressure,  and  passing  over  of  the  finger 
tips,  will  have  to  be  stronger  for  the  organs  in  the  chest,  than 
for  those  in  the  abdomen;  and  stronger  for  those  parts  covered 
by  the  organs  of  little  density  and  little  tension,  than  for  those 
covered  by  very  dense  and  well  stretched  organs;  and  stronger 
for  the  parts  lying  far  beneath  the  surface  of  the  body,  than  for 
those  lying  directly  under  it. 

If  the  finger  is  not  well  pressed  down  the  vibration  will 
be  a  surface  vibration,  which  may  act  by  completely  disturbing, 
and  induce  a  series  of  fractional  sounds  and  echoes,  in  the  layers 
of  different  density,  and  this  may  hinder  us  from  getting  at  all 
to  the  part  which  is  to  be  examined.  Here  we  must  try  and 
avoid  the  mistakes  which  have  led  to  negative  results  in  the 
examinations  of  different  investigators,  as  Bouveret,  Egger, 
Grote  and  a  few  others.  In  such  a  case  one  of  these  gentle- 
men would  describe  the  lines  of  the  skin,  and  not  the  projec- 
tion or  part  of  the  organ  which  he  tried  to  investigate  by  his 
examination. 

(2)  When  the  vibration  is  transmitted  to  the  organ  it  will 
vibrate  according  to  its  density  and  tension.     The  vibrations 
of  the  organ  will  transmit  themselves  to  the  organs  surround- 
ing it  and  will  undergo  a  series  of  reflexions  and  breaks,  while 
passing  through  the  intervening  layers.     To  collect  these  vibra- 
tions it  is  necessary  that  the  little  stem  or  rod  of  the  Phonen- 


Phonendoscopy  of  the  Organs.  29 


doscope  be  used,  in  order  to  produce  an  artificial  continuity  in 
the  density  of  the  tissue,  lying  between  the  organ  and  the 
Phonendoscope,  and  be  made  to  vibrate  ;  and  thus,  the  little 
stem  itself  must  be  pressed  upon  the  tissue  of  the  organ  which 
is  to  be  examined.  Consequently,  the  little  stem  must  be  well 
pressed  against  the  wall  of  the  body,  and  must  be  placed  upon 
the  point  which  is  in  direct  contact  with  the  organ  which  is  to 
be  examined.  By  not  paying  attention  to  these  simple  rules 
the  results  will  be  negative.  It  is  understood  that  we  can  only 
approximate  fixed  points  of  observation.  It  is  therefore  neces- 
sary that  we  make  out,  first  the  organs  lying  near  the  surface, 
and  then  the  organs  lying  lower  down,  and  then  by  putting  the 
little  stem  or  rod  on  the  space  which  is  left  free.  In  this  way 
I  now  would  like  to  describe,  first  the  lower  limits  of  the  right 
lung,  before  describing  the  liver  ;  and  the  limits  of  the  left 
lung,  before  the  spleen  ;  and  the  inner  edge  of  the  lungs,  before 
we  look  for  the  heart  ;  the  lower  edge  of  the  liver,  before  mark- 
ing the  stomach,  or  the  right  kidney,  or  the  colon  on  the  right 
side  ;  the  lower  edge  of  the  stomach  and  the  spleen,  before  the 
colon  on  the  left ;  those  of  the  spleen  behind,  before  marking 
the  left  kidney.  In  this  way  the  topography  of  the  intestines 
will  become  very  simple,  and  it  will  be  sufficient  to  remember 
the  most  elementary  anatomical  knowledge,  in  order  to  make 
an  exact  outline  of  the  various  parts  of  the  body. 

(3)  Noticing  of  the  vibrations  which  are  produced  is  in 
itself  very  simple.  If  you  put  the  little  stem  on  the  vibrating 
body  the  vibrations  transmitted  by  the  little  stem  to  the  vibrat 
ing  plate  of  the  Phonendoscope  will  become  condensed  in  its 
little  air  chamber,  and  by  means  of  the  two  tubes  reaches  the 
outer  ear  at  the  tympanum  which  will  thus  be  caused  to  vibrate. 
We  have,  therefore,  according  to  the  physical  laws  which  gov- 
ern this  department  of  science,  the  sensation  of  a  more  or  less 
powerful  noise.  This  proves  the  fact  that  when  the  little  stem 
is  in  contact  with  any  part  of  the  body  it  conducts  all  the  vibra- 
tions to  the  ear,  which  are  produced  upon  the  surface  of  the 
body,  and  which  correspond  to  that  part  of  the  body  which  is 
being  examined.  If  the  vibrations  are  caused  in  the  skin  or 
outer  limits  of  a  part  of  the  body,  then  they  are  not  at  all,  or 
but  very  slightly,  perceived.  It  is  necessary  to  mark  the  point 


30  Phonendoscopy  of  the  Organs, 

with  a  pencil  where  the  vibration  ceases  or  diminishes.  In 
comparing  all  the  parts  obtained  in  this  way,  in  one  line,  we 
will  get  a  figure  which  represents  an  outline  of  that  part  of  the 
body.  This  outline  may  be  traced  on  the  even  walls  of  the 
body  (front  or  back,  as  the  case  requires),  and  almost  of  the 
same  size  as  the  organ.  On  the  sides  however  this  outline  will 
be  larger.  These,  then,  are  the  laws  which  govern  the  shadow 
to  be  observed,  and  one  and  the  same  part  will  give  different 
figures  upon  the  wall  of  the  body,  according  to  the  position 
assumed  by  the 'patient.  In  this  way  the  conical-shaped  heart 
will  furnish  an  outline  more  like  a  round  or  triangular  figure, 
according  as  to  whether  it  is  more  or  less  vertical  to  the  wall 

of  the  chest. 

V. 

The  importance  of  this  really  extraordinary  result  received 
by  such  simple  means  is  confirmed  in  the  post-mortem  exami- 
nations (Schwalbe,  Roux),  and  by  experiments  made  upon 
animals,  and  especially  by  means  of  the  radioscope,  which  also 
brings  to  light  the  changes  taking  place  in  the  different  organs. 
If,  for  instance,  you  make  an  examination  of  the  lower  edge  of 
a  lobe  of  the  lungs,  and  cause  the  patient  to  exhale  and  inhale, 
while  passing  over  the  part  your  finger  in  the  proper  manner, 
you  will  see  the  line  previously  marked  upon  the  skin  displac- 
ing itself,  and  moving  either  up  or  down,  although  the  little 
stem  remains  in  the  same  place,  and  by  this  pressure  the 
displacement  of  the  skin  is  prevented.  You  also  see  this  when 
tracing  the  outline  of  the  empty  stomach,  and  while  allowing 
the  little  stem  to  rest  upon  the  same  spot.  But  fill  it  with 
liquid  and  all  the  edges  of  the  neighboring  organs  will  displace 
themselves.  The  most  clear  and  simplest  experiment  is  the 
following  :  You  mark,  in  a  standing  position,  the  upper  edge 
of  the  liquid  contents  of  the  stomach,  and,  while  leaving  the 
little  stem  in  its  position,  raise  with  the  hand  the  lower  part  of 
the  stomach.  You  continue  at  the  same  time  to  pass  the  finger 
in  a  parallel  line  over  the  nivean  of  the  liquid,  and  you  find 
that  this  displaces  itself  upward,  according  to  the  pressure 
brought  to  bear  against  it  at  the  lower  part.  In  relieving  the 
pressure  the  nivean  of  the  liquid  -will  go  down  and  take  its 
former  position. 


Phonendoscopy  of  the  Organs.  3 1 


When  we  witness  such  a  simple  and  clear  experiment  we 
cannot  doubt  the  results  of  the  method,  and,  I  repeat  it,  that 
the  isolated  negative  results  are  simply  to  be  attributed  to  the 
insufficient  knowledge  of  the  common  laws  and  their  partial 
application  in  our  method. 

VI. 

The  outlines  of  the  diagram  of  organs  marked  in  such  a 
way  give  us  figures,  very  different  from  those  which  have  become 
traditional  in  the  manuels  of  semiology.  For  this  very  reason 
either  the  one  or  the  other  finds  fault  with  the  Phonendoscope 
for  giving  us  an  ideal  and  not  the  real  figure  of  the  organ.  But 
this  finding  fault  is  most  unjust.  The  ordinary  percussion  gives 
us  the  outlines  of  the  organs  very  differently,  because  it  is 
almost  always  performed  while  the  individual  is  lying  down, 
and,  therefore,  the  organs  are  drawn  into  different  positions, 
and  are  displaced  backwards.  The  outline  made  in  this  way 
cannot  be  the  same  as  the  one  received  with  the  Phonendo- 
scope, which  is  generally  made  while  the  individual  is  stand- 
ing. And  furthermore,  in  practicing  phonendoscopy  on  a  per- 
son lying  down  it  will  give  more  perfect  results  than  the  ordi- 
nary method  of  percussion.  We  are  used  to  seeing  in  the 
manuels  of  semiology,  as  a  rule,  the  organs  drawn  in  the  ordi- 
nary position,  and  in  their  mutual  relations,  as  they  are  shown 
in  the  manuels  of  anatomy.  But  the  form,  position  and  mutual 
relations,  as  they  are  represented  after  death,  are  not  the  same 
as  during  the  life,  whether  it  be  in  a  physiological  view,  or 
during  a  change  produced  by  disease.  The  drawings  made  by 
means  of  the  Phonendoscope,  by  the  outlining  of  the  organs  on 
the  wall  of  the  body,  as  it  were,  by  the  shadow  of  the  organ , 
the  harmony  of  the  phonendoscopic  diagrams  with  those 
received  by  the  X-rays  (7)  is  the  clearest  proof  of  the  correct- 
ness of  this  assertion. 

VII. 

The  application  of  the  method  in  medicine  and  in  the 
sciences  related  to  it  are  very  numerous.  Besides  the  physio- 
logical and  pathological  studies  about  the  lungs,  heart,  liver, 
spleen,  colon  and  kidneys,  we  have  a  large  quantity  of  alto- 
gether new  productions,  in  studies  about  the  diseased  products, 

(7)  Congress  fur  innere  Medicine,  Berlin,  1897. 


32  Phonendoscopy  of  the  Organs. 

transfilitration,  new  formations  and  about  the  changes  caused 
by  them  in  the  various  organs. 

Here  I  will  try  to  give  the  exact  indications  for  the  study 
of  the  stomach,  the  changes  of  its  volume,  the  form,  the  posi- 
tion and  the  relations  between  the  whole  and  its  contents.  The 
stomach  cannot  be  considered  as  being  like  any  other  organ. 
It  has  thin  walls,  and  can  only  be  studied  by  means  of  its  con- 
tents. If  the  stomach  contains  nothing  but  gases  or  liquid 
material,  then  il  acts  just  the  same  as  any  other  organ  ;  but  if 
it  contains  liquids  and  gases  it  must  be  looked  upon  as  com- 
posed of  a  gas  chamber  and  liquid  chamber  of  different  den- 
sity and  tension.  The  total  outline  will  therefore  be  obtained 
by  the  phonendoscopy  of  the  gas  chamber  and  of  the  liquid 
chamber.  We  therefore  require  two  points  of  observation. 
We  must  first  set  the  little  stem  upon  the  liquid  chamber  and 
then  upon  the  gas  chamber.  These  are  like  two  separated 
organs,  which  are  to  be  marked  upon  the  skin  by  diagrams, 
one  after  the  other,  and  which  give  the  entire  outline  of  the 
stomach,  by  uniting  them  both  into  a  single  diagram. 

In  my  lectures  to  the  class  (8)  I  have  demonstrated 
already  that  it  is  necessary  to  draw,  first  the  lower  edge  of  the 
liver,  and  that  in  putting  the  little  rod  below  that  line,  on  the 
left  hemiclavicular  line,  we  can  find  the  outline  of  the  stomach. 
This  is  the  ordinary  rule,  but  there  are  also  exceptions,  and  it 
is  well  to  know  them  in  order  to  avoid  any  mistakes. 

After  taking  food,  when  the  liver  is  thick  and  sinks  down 
to  the  left,  and  if  the  stomach  contains  much  liquid,  it  is  im- 
possible fo  find  the  gas  chamber,  which  is  then  entirely  covered 
by  the  liver.  Also  if  the  spleen  or  the  kidneys  are  enlarged, 
and  the  stomach  is  almost  entirely  covered  by  these  organs. 
But  if  the  stomach  is  pressed  down  by  pressure  from  above,  or 
is  pushed  away  by  a  dense  mass  which  is  stronger  than  its 
walls,  then  the  gas  and  liquid  chambers  are  fully  uncovered 
and  are  always  easily  traced,  even  though  a  person  suffer  with 
ascitis.  In  this  way  you  can  keep  the  drawings,  and  the  rela- 
tions of  the  stomach  to  the  other  neighboring  organs,  by 
photography  or  chrornography  and  perceive  from  them  the 

(8)  The  three  main  forms  of  the  stomach,  the  gastric  curve  within  twenty-four  hours. 
The  difference  in  the  digestion  of  liquids.     (22-2^  97.) 


I'honendoscopy  of  the  Organs.  33 


displacements  by  the  process  of  digestion,  and  from  many  other 
causes.  It  is  most  interesting  to  follow  in  this  way  for  several 
hours  the  displacement  of  the  organ  and  the  changes  of  its 
contents,  and  to  be  able  to  observe  the  action  of  the  different 
foods  and  medicaments,  by  the  comparison  of  the  different 
drawings.  In  this  way  I  have  been  able  to  draw  the  first  com- 
plete gastric  curve  within  twenty-four  hours,  and  this  draw- 
ing, the  first  one  made,  until  now,  I  have  deposited  in  the 
physiological  laboratory  of  the  University  of  Moscow. 

Before  finishing  I  wish  to  call  your  attention  again  to  the 
importance  and  simplicity  of  the  method. 

With  one  single  instrument,  the  Phonendoscope,  and  a 
pencil,  with  the  aid  of  the  point  of  the  finger,  and  without  the 
least  inconvenience  to  the  individual  under  examination,  you 
can  draw  all  parts  of  the  body  in  a  short  time. 

For  this  reason,  phonendoscopy,  during  the  last  three 
years  of  its  existence,  has  come  into  quite  extensive  use,  and 
will  slowly  extend  itself  more  and  more,  and  certainly  the 
time  is  not  far  distant  when  it  will  be  mentioned  in  all  the 
manuels  of  semiology,  besides  the  simple  methods  of  percus- 
sion and  auscultation. 

A  new  method,  in  order  to  make  its  way  through  the 
world,  must  first  become  known  and  gather  support.  It  must 
become  known  to  the  hospital  physicians,  as  well  as  the  private 
practitioners,  and  must  be  supported  by  the  investigators  who 
are  the  real  friends  of  scientific  truth  and  discoveries. 

The  examinations  following  this  lecture  were  witnessed, 
each  time,  by  five  physicians  at  once,  and  which  resulted  in 
quickly  and  easily  fixing  the  lungs,  the  heart,  the  liver,  the 
stomach,  the  spleen,  and  their  outlines,  making  apparent  the 
displacements  of  the  lungs  during  inhalation  and  exhalation, 
the  shifting  of  the  stomach,  while  taking  liquid,  and  also  the 
changes  in  the  nivean  of  the  liquid  in  the  stomach,  by  lifting 
the  lower  part  of  it,  pressing  with  the  hands,  and  the  sinking 
down  of  it  by  ceasing  to  press. 

The  points  by  which  the  line  tracing  the  organ  is  formed 
were  indicated  by  those  who  made  the  examination,  when  they 
could  distinctly  hear  the  change  in  the  sound,  which  was  pro- 
duced by  passing  the  finger  with  some  pressure  over  the  skin. 


CHAPTER    III. 

DIRECTIONS  FOR  OUTLINING  THE  VARIOUS 
ORGANS. 

ANTERIOR  PORTION  OF  THE  BODY. 

THE  LUNGS. 


PHONf  Nt-OSCOP:C    FIGURE    OF    LUNGS. 


Place  the  Phonendoscope  above,  upon,  and  below  the 
clavicle  for  the  upper  lobes  (1-2)  ;  in  the  third  intercostal 
space  for  the  (4)  middle  lobe  ;  in  the  fourth  for  the  lower  (5). 
Do  not  stroke  too  hard.  In  this  way  you  can  readily  distinguish 
the  beginning  of  the  lung,  its  divisions  into  lobes,  and  the 
overlapping  of  the  same.  When  a  pleuritic  effusion  is  present, 
put  the  instruments  in  the  same  positions,  and,  after  examining 
in  the  upright  and  reclining  positions,  place  the  patient  first 
on  the  right  and  then  on  the  left  side,  to  ascertain  the  variation 
in  the  level  of  the  fluid.  Stroke  vigorously. 


Directions  for  Outlining  the  Various  Organs. 


35 


THE  HEART. 


PHONENDOSCOPIC    FIGURE    OF    HEART. 


To  determine  the  position  of  the  heart,  place  the  Phonen- 
doscope  in  the  left  parasternal  line,  fourth  intercostal  space  ; 
for  the  right  ventricle,  a  little  lower  to  the  left ;  for  the  right 
auricle,  a  little  lower  to  the  right ;  for  the  left  ventricle,  a  little 
higher  to  the  left ;  for  the  large  vessels,  a  little  higher  to  the 
right  (arch  of  aorta,  etc.)  ;  vigorous  strokes.  In  this  way  we 
can  determine  the  exact  size  and  boundaries  of  the  heart,  its 
division  into  ventricles  and  auricles,  and  the  position  of  the 
large  vessels. 


Directions  for  Outlining  the  Various  Organs. 


THE  LUNGS  AND  HEART. 


PHONCNDOSCOPIC    FIGURE    OF    LUNGS    AND    HEART. 


Directions  for  Outlining  the  Various  Organs.  37 


THE  LIVER  AND  COLON. 


PHONENDOSCOPIC    FIGURE    OF    LIVER 
AND    COLON. 


THE  LIVER. — Place  the  Phonendoscope  in  the  following 
positions  successively  :  Beneath  the  xyphoid  appendix  in  the 
right  mamillary  line,  in  the  seventh  intercostal  space  ;  in  the 
ninth  intercostal  space  over  the  midaxillary  line.  Vigorous 
strokes. 

THE  COLON. — For  the  caecum  and  ascending  colon  place 
the  Phonendoscope  in  the  right  iliac  fossa,  beneath  the  free 
border  and  in  the  anterior  axillary  and  midaxillary  lines.  For 
the  transverse  colon,  on  two  or  three  points,  according  to  the 
breadth,  above  a  line  which  passes  from  right  to  left  over  the 
umbilicus  and  strikes  the  left  free  border  between  the  midaxil- 
lary and  posterior  axillary  lines.  For  the  descending  colon, 
beneath  the  left  free  border  in  the  midaxillary  line  and  also 
near  the  anterior  superior  spine  of  the  ileum.  Stroking  varies 
with  the  nature  of  the  contents. 


Directions  for  Outlining  the  I'arivt/s 


THE  STOMACH  AND  COLON. 


PHONENOOSCOPIC    FIGURE    OF    STOMACH    AND 
COLON,    WITH    EXAMINATION    POINTS. 


THE  STOMACH. — Place  the  Phonendoscope  in  the  seventh 
intercostal  space,  left  midclavicular  line,  and  then  on  the  linea 
alba  near  the  left  free  edge  of  the  ribs.  When  the  stomach  is 
full,  place  the  instrument  just  below  the  greater  curvature. 
We  can  thus  distinguish  the  pylorus,  cardia,  the  coils  of  the 
intestine,  and  the  nature  of  their  contents,  whether  fluid  or 
gaseous,  and  also  the  change  in  place  and  form  of  the  organs 
when  the  position  of  the  patient  is  shifted.  Stroke  vigorously 
for  fluid,  and  lightly  for  gaseous  contents. 


Directions  for  Outlining  the  Various  Organs.  39 


PHONENDOSCO 


4O  Directions  for  Outlining  tlie  Various  Organs 


PHONENDOSCOPIC    FIGURE    OF    FRONT    SIDE    OF 
BODY,    WITH    EXAMINATION    POINTS. 


BLADDER. — Place  the  Phonendoscope  in  the  linea  alba 
above  the  symph3'sis  pubis.  Stroke  gently  when  the  bladder  is 
empty,  vigorously  when  it  is  full  of  fluid. 

ASCITIC  FLUID. — Place  the  Phonendoscope  on  either  side 
in  the  anterior  axillary  line  and  in  the  linea  alba  on  a  level 
with  the  umbilicus,  having  the  patient  change  from  the  up- 
right to  the  reclining  position,  and  even  stand  on  his  feet. 
Stroke  vigorously. 

NEW  GROWTHS,  also  deeply  situated  organs,  as  the  kidneys 
and  spleen,  can  be  outlined  by  placing  the  Phonendoscope  over 
the  centre  of  the  organ  and  stroking  the  overlying  region. 
Enlarged  glands  can  be  studied  in  the  same  way. 


Directions  for  Outlining  the  Various  Organs.  41 


POSTERIOR  SURFACE  OF  BODY. 


PHONENDOSCOPIC    FIGURE    OF    BACK    SIDE    OF 
BODY,    WITH    EXAMINATION     POINTS. 

LUNGS.  —  Place  the  Phonendoscope  on  either  side  in  the 
scapular  line  at  a  level  between  the  first  and  fourth  dorsal 
vertebrae  for  the  upper  lobes,  and  between  the  seventh  and 
tenth  for  the  lower  lobes. 


.  —  Place  the  Phonendoscope  in  the  right  scapular 
region  at  the  level  of  the  twelfth  dorsal  vertebrae. 

SPLEEN.  —  Place  the  Phonendoscope  on  the  left  side  in  the 
posterior  axillary  and  midaxillary  lines  and  in  the  interspaces 
between  the  last  ribs. 

KIDNEYS.  —  Place  the  instrument  just  within  the  semi- 
scapular  line,  immediately  below  the  regions  of  the  liver  and 
the  spleen. 


42  Directions  for  Outlining  the  I'arious  Organs. 


PHONENDOSCOPY    OF    NATURAL    VIBRATIONS. 


Directions  for  Outlining  the  I'arioits  Organs.  43 


PHONENDOSCOPY    OF    MUSCULAR    SOUNDS. 


44  Directions  for  Outlining  the  Various  Organs. 


PHONENDOSCOPY    OF    VIBRATIONS    ARTIFICIALLY    PRODUCED. 


Directions  for  Outlining  the  Various  Organs.  45 


PHONENDOSCOPY    OF    LARYNX. 


46  Directions  for  Outlining  the  Various  Organs. 


PHONENDOSCOPY    OF    VIBRATIONS    ARTIFICIALLY    PRODUCED. 


Directions  for  Out!  in  ing  the  I 'ar  ions  Organs.  47 


COMPARATIVE    PHONENDOSCOPY. 


PHONENOOSCOPIC    EXAMINATION    OF    HORSE. 


FORKED  ATTACHMENTS  FOR  THE 
PHONENDOSCOPE. 


The  instances  in  which  the  Phonendoscope  may  be  used 
simultaneously  by  a  number  of  physicians  are  too  numerous  to 
mention.  It  very  often  happens  that  physicians  when  in  con- 
sultation want  to  examine  the  same  patient  at  the  same  time. 
If  the  physician  only  uses  one  ear  then  the  regular  tubes 
that  come  with  the  Phonendoscope  will  suffice,  but  if  both  the 
ears  of  each  examiner  are  to  be  used  then  of  course  four  tubes 
are  required.  For  this  purpose  we  have  a  set  of  tubes  as  shown 
in  the  center  of  the  illustration  in  which  it  will  be  noticed  that 
four  tubes  are  attached.  This  simply  is  a  Y-shaped  fork. 
Thereby  two  or  four  physicians  are  enabled  to  examine  with 
the  same  Phonendoscope.  The  figure  on  the  left  shows  a  triple 
fork,  by  means  of  which,  either  three  or  six  physicians  may 
examine  at  once  with  the  same  Phonendoscope.  The  other 
illustration  shows  a  four-forked  instrument  with  which  four  or 
eight  physicians  can  examine  at  the  same  time  with  the  one  Pho- 
nendoscope. These  attachments  are  very  extensively  used  in 
the  European  Universities,  especially  during  lectures,  and  when 
students  are  being  instructed.  These  instruments  were  all 
made  by  George  P.  Pilling  &  Son,  Philadelphia,  and  are  most 
satisfactory,  being  made  precisely  like  the  samples  obtained 
from  Europe. 


CHAPTER   IV. 


THE    RELATION    BETWEEN   THE   OUTLINES  OF 

THE  INTERNAL  ORGANS  OF  THE  BODY  AS 

DETERMINED   BY   THE   X-RAYS  AND  BY 

THE  PHONENDOSCOPE.    THE  LAWS 

GOVERNING  THE  TWO  METHODS. 

Those  organs  whose  molecular  vibrations  in  the  form  of 
light  or  sound  make  no  sensible  impression  upon  our  sight  or 
hearing  without  the  use  of  specially  constructed  apparatus,  are 
at  the  present  time  directly  appreciable  to  the  eye  and  the  ear, 
on  the  one  hand  by  the  aid  of  the  X-rays  and  Fluoroscope,  and 
on  the  other  by  the  aid  of  the  Phonendoscope. 

Skiascopy,  therefore,  the  science  of  the  X-rays  and  the 
Fluoroscope,  and  phonendoscopy,  the  science  of  auscultation 
with  the  aid  of  the  Phonendoscope,  are  two  new  and  far-reach- 
ing methods  of  studying  the  condition  of  the  internal  organs 
of  the  body  both  in  health  and  disease;  but  these  methods  are 
still  in  their  infancy. 

Neither  the  vibrations  of  the  cathode  rays  nor  the  sound- 
waves produced  in  the  various  organs  of  the  body  are  apprecia- 
ble to  the  eye  or  the  ear,  unless  the  eye  be  aided  by  the  Fluoro- 
scope, and  the  ear  by  the  Phonendoscope. 

While,  on  the  one  hand,  the  invisible  vibrations  of  the 
X-rays  penetrate  the  different  viscera  of  the  body  with  a  facility 
which  varies  with  the  shape,  density  and  mutual  relations  of 
the  latter,  and  are  then  made  visible  in  the  Fluoroscope,  or  are 
fixed  upon  a  photographic  plate,  so  on  the  other  hand,  the 
friction  of  the  finger-tip  across  the  surface  of  the  body  gives 
rise  to  vibrations  which  are  inaudible  to  the  most  acute  ear, 
but  which  are  taken  up  and  intensified  by  the  Phonendoscope, 
and  so  rendered  distinctly  audible.  In  this  way  the  Phonendo- 
scope outline  of  any  desired  organ  may  be  traced  upon  the  sur- 
face of  the  body. 


X-Ray  and  the  Phonendoscope.  51 


Skiascopy  and  phonendoscopy  are  therefore  two  new  clini- 
cal procedures,  which  give  like  results  by  different  methods, 
the  one  rendering  vibrations  sensible  to  the  eye,  the  other  to  the 
ear.  Both  methods  may  be  made  to  give  permanent  results, 
the  former  by  means  of  the  X-ray  photographs,  the  latter  by 
means  of  the  phonendoscopic  chart. 

The  similarity  of  these  results  has  led  me  to  look  for  some 
constant  relation  between  the  two  procedures  in  the  hope  of 
coming  to  some  useful  and  definite  conclusions.  My  efforts 
were  rewarded  with  the  most  satisfactory  results,  and  I  can  say 
without  hesitation  that  both  methods  of  procedure  are  governed 
by  the  same  fundamental  laws,  and  although  each  has  its  own 
peculiarities  and  variations  the  results  of  both  are  the  same. 

It  was  this  consideration  of  the  similarity  of  two  methods 
of  investigation  so  apparently  different,  one  of  which  was  dis- 
covered in  Germany,  the  other  in  Italy,  which  has  afforded  me 
the  opportunity  of  addressing  this  assembly  to-day.  I  there- 
fore beg  to  express  my  thanks  to  you  for  the  honor  of  being 
present  among  you,  and  of  being  permitted  to  learn  of  progress, 
of  new  discoveries,  of  the  fruits  of  investigation  and  experi- 
ment from  the  lips  of  the  most  prominent  physicians  of  the 
German  Empire. 

You  are  well  acquainted  with  the  apparatus  necessary  for 
skiascopy;  permit  me  to  describe  the  instruments  used  in  pho- 
nendoscopy. They  are  very  few,  consisting  in  fact  of  but  one 
instrument,  the  Phonendoscope.  The  tip  of  the  finger  is  used 
to  stroke  the  skin  for  the  production  of  the  necessary  vibra- 
tions, and  an  ordinary  lead  pencil  suffices  to  draw  the  outlines 
of  the  organs  upon  the  skin. 

The  Phonendoscope  was  invented  at  my  suggestion  about 
four  years  ago,  and  is  the  work  of  my  colleague,  Professor 
Bazzi.  Since  that  time  many  imitations  and  modifications  of 
the  instrument  have  been  made;  these  are,  however,  mere 
variations  in  the  shape  of  the  instrument  and  not  in  the  princi- 
ple of  its  construction. 

With  the  aid  of  the  Phonendoscope  we  can  examine  a 
large  or  a  small  portion  of  the  body-surface  with  little  differ- 
ence in  its  sensitiveness.  In  fact  it  is  just  this  power,  afforded 
us  by  the  use  of  the  localizer,  of  examining  one  very  minute 


52  X-Ray  and  the  'Phonendoscope. 


portion  of  the  body  at  a  time,  which  has  enabled  me  to  develop 
a  method  of  investigation  which  was  never  dreamed  of  before. 

On  account  of  the  extreme  sensitiveness  of  the  instrument 
I  have  ceased  using  the  forcible  vibrations  produced  by  the 
voice  or  by  percussion,  and  have  learned  to  utilize  instead  the 
very  delicate  vibrations  produced  by  a  gentle  stroke  of  the 
finger  across  the  skin. 

The  instrument  is  manufactured  in  Germany  in  the  city  of 
Cassel  by  the  firm  of  Martin  Wallach.  This  house  not  only 
manufactures  a  perfect  instrument  but  spares  no  pains  to  dis- 
tribute the  same  to  all  parts  of  the  world.* 

We  now  come  to  the  subject  proper  of  our  paper. 

(1)  Neither    skiascopy    nor    phonendoscopy    cause    the 
patient  any  pain. 

(2)  Neither  the  passage  of  the  cathode  ray  through  the 
body  nor  the  scraping  of  the  finger  by  which  the  vibrations  for 
the  Phonendoscope  are  produced  cause   the  patient  any  pain, 
although  the  former  occasionally  gives  rise  to  a  burning  or 
crawling  sensation,  in  the  skin  the  latter  to  an  occasional  tick- 
ling sensation. 

(3)  Neither  the  Fluoroscope,  the  sensitive  photographic 
plate  for  the  X-ray  picture,  nor  the  localizer  of  the  Phonendo- 
scope give  rise  to  any  other  sensation  to  the  patient  than  that 
of  mere  touch.     The  eye  of  the  observer  is  apt  to  become  tired 
after  a  prolonged  examination  with  the  Fluoroscope,  as  is  also 
the  ear  of  the  physician  using  the  Phonendoscope;   but  in  the 
latter  case  the  exhaustion  is  by  no  means  as  marked  as  in  the 
former. 

(4)  In  order  to  make  the  X-ray  shadow  in  the  Fluoroscope 
clear  and  distinct  the  instrument  must  be  applied  to  the  body 
at  the  point  at  which  the  organ  to  be  examined  is  most  super- 
ficial.    In  like  manner  the  Phonendoscope  must  be  applied  to 
the  surface  directly  over  the  desired  organ,  so  as  to  bring  it  as 
far  as  possible  into  continuous  contact  with  the  organ  itself. 

(5)  As  the  intensity  of  the  X-rays  must  be  adjusted  ac- 
cording to  the  distance  of  the  organ  from  the  surface  of  the 
body,  so  it  is  also  important  to  regulate  both   the   pressure 


'American  ageiits  are  George  P.  Pilling  &  Son,  Philadelphia. 


X-Ray  and  the  Phonendoscope.  53 


exerted  upon  the  localizer  of  the  Phonendoscope  and  the  force 
of  the  strokes  by  which  the  necessary  vibrations  are  produced, 
according  to  the  position  of  the  organ  to  be  examined .  Very 
powerful  X-rays  will  pass  through  the  superficial  and  less  dense 
structures  of  the  body  without  producing  a  shadow;  in  using 
the  Phonendoscope,  if  too  much  force  be  used  in  stroking  the 
skin  the  pressure  of  the  finger  will  increase  the  tension  of  the 
superficial  structures  and  the  vibrations  will  be  transmitted  to 
the  deeper  organs;  and  if  too  much  pressure  be  made  upon  the 
Phonendoscope,  the  superficial  vibrations  will  be  suppressed 
and  only  those  coming  from  the  deeper  organs  will  be  trans- 
mitted through  the  instrument. 

(6)  In  using  the  X-rays  it  is  best  to  place  the  bulb  oppo- 
site the  viscus  to  be  examined  and  the  Fluoroscope  directly  over 
it,  or   if  the   viscus  be  a  large  one  the  Fluoroscope  must  be 
placed  upon  several  different  parts  of  its  surface.     In  using  the 
Phonendoscope,  it  should  likewise  be  placed  directly  over  the 
organ  at  one  or  more  points  according  to  the  size  of  the  organ, 
and  the  finger  producing  the  vibration  should  move  in  a  circu- 
lar manner  about  the  point  of  contact  of  the  Phonendoscope 
with  the  body. 

(7)  With  both  the   X-rays  and  the   Phonendoscope  we 
may  obtain  either  a  temporary  result  or  a  permanent  record. 

(8)  In  the  case  of  the  X-rays  we  may  be  satisfied  with  a 
simple  examination  of  the  viscera  with  the  Fluoroscope  with 
merely  outlining  the  organs  upon  the  skin. 

(9)  A  permanent  record  can  be  obtained  with  either  pro- 
cedure by  means  of  a  photographic  plate  or  a  camera  ;  but  a 
phonendoscopic  chart  can  be  rapidly  made  if  the  outlines  be 
drawn  upon  the  skin  with  copying  ink  and  a  copy  be  made 
directly  upon  a  sheet  of  paper. 

(10)  In  order  to  obtain  clear  and  trustworthy  results  with 
either  the  X-rays  or  the  Phonendoscope,  a  thorough  knowledge 
of  the  processes  involved,  an  impartial  judgment  and  technical 
skill  are  presupposed  requirements. 

(u)  The  outline  obtained  by  either  of  these  two  proce- 
dures is  not  an  exact  representation  of  the  outline  of  the  viscus 
itself ;  it  represents,  rather,  in  one  case  the  shadow  of  the  viscus 


X-Ray  and  the  Phonendoscope. 


upon  the  Fluoroscope,  in  the  other  the  projection  of  the  viscus 
upon  the  surface  of  the  body.  The  farther  a  viscus  is  removed 
from  the  surface  of  the  body  the  more  will  its  representation 
be  modified  in  various  ways.  The  position  of  the  Fluoroscope 
influences  the  shape  of  the  shadow.  If  the  Fluoroscope  is  in 
contact  with  one  part  of  the  body  surface,  for  instance,  the 
anterior  surface,  the  sides  of  the  body  and  parts  of  organs 
situated  within  the  sides  will  be  separated  from  the  Fluoroscope 
by  some  distance,  owing  to  the  oval  contour  of  the  body  > 
hence  arises  a  certain  amount  of  distortion  of  the  outline,  or  a 
partial  or  general  increase  of  its  size.  In  the  case  of  the 
Phonendoscope  also,  the  fact  that  it  can  be  brought  to  bear 
upon  the  superficial  surface  of  the  organ  only,  and  not  even  in 
actual  contact  with  that,  and  the  fact  that  the  body  surface  is 
rounded  cause  the  outline  to  assume  a  shape  which  is  not  the 
actual  shape  of  the  organ  itself. 

(12)  The  solid  viscera  throw  a  dark  shadow  upon  the 
Fluoroscope,  whose  intensity  depends  upon  the   density  and 
thickness  of  the  viscus.     With  the  Phonendoscope  it  is  found 
that  these  same  viscera  give  powerful  vibrations  whose  inten- 
sity is  directly  proportionate  to  the  thickness  and  density  of 
the  viscera. 

(13)  The  shadow  thrown  upon  the  Fluoroscope  by  a  solid 
viscus  situated  in  the  posterior  part  of  the  body  is  darker  in 
the  center  of  the  shadow  and  lighter  around  its  margin.    With 
the  Phonendoscope  it  is  found  that  this  same  viscus  gives  rise 
to  vibrations  which  are  more  powerful  at  the  center,  where  the 
viscus  touches  the  body  wall,  while  towards  its  borders,  where 
the   viscus   is  separated  from  the  body   wall,  the  vibrations 
become  less  and  less  intense. 

(14)  Viscera,  consisting  of  one  or  more  cavities  contain- 
ing gas  give  a  brighter   projection  upon  the  Fluoroscope  if  the 
tension  of  the  gas  is  great ;  and  the  greater  the  pressure  of  gas 
in  the  viscera,  the  higher  will  be  the  pitch  of  the  vibrations  in 
the  Phonendoscope. 

(15)  In  a  hollow  viscus  containing  both  gas  and  fluid, 
the  part  containing  gas  will  throw  a  light  shadow  upon  the 
Fluoroscope,  the  part  containing  fluid,  a  dark  shadow.     In  using 
the  Phonendoscope  the  part  containing  gas  can  be  distinguished 


X-Ray  and  the  Phonendoscope.  55 


from  that  containing  fluid  by  the  fact  that  the  pitch  of  the 
vibrations  over  the  gas  is  higher  than  over  the  fluid. 

(16)  Osseous  structures  throw  a  very  dark  shadow  upon 
the  Fluoroscope,  and  their  vibrations  in  the  Phonendoscope  are 
high  pitched.     The  shadows  which  any  part  of  the  body  con- 
taining bone  throws  upon  the  Fluoroscope  consists  of  the  shadow 
of  the  bone  plus  the  shadow  of  any  organs  lying  behind  the 
bone  ;  the  tone  of  the  vibrations  heard  in  the  Phonendoscope 
over  a  long  part  is  a  result  of  the  blending  of  the  vibrations 
peculiar  to  the  bone  with  the  vibrations  from  the  underlying 
structures.     The  shadow  thrown  upon  the  Fluoroscope  by  an 
organ  enclosed  in  a  bony  cavity  is  almost  entirely  obscured  by 
the  darker  shadow  of  the  bone  ;  in  like  manner  the  Phonendo- 
scope is  unable  to  detect  the  vibrations  due  to  such  organs  on 
account  of  the  predominance  of  the  more  powerful  bony  vibra- 
tions. 

(17)  The  movements  of  the  various  viscera,  whether  physi- 
ologically or  artificially  produced,   can  be  distinctly  seen  in 
the  Fluoroscope  by  the  motion  of  their  shadows,  provided,  of 
course,  that  the  X-ray  bulb  and  the  Fluoroscope  remain  station- 
ary.    In  the  case  of  the  Phonendoscope,  if  the  point  of  origin 
of  the  vibrations  and  the  situation  of  the  instrument  are  fixed, 
any  change  in  the  position  of  the  underlying  viscera  can  be 
determined  by  a  change  in   their  outlines  as  traced  upon  the 
skin.     But  such  movements  can  be  seen  in  the  Fluoroscope  in  a 
limited  number  of  organs  only,  such  as  the  bones,  the  dia- 
phragm, the  heart  and  the  lungs,  whereas  the  Phonendoscope 
can  be  used  on  any  part  of  the  body  and  upon  any  viscus  or 
part  of  a  viscus,  and  upon  accumulations  of  fluid  in  the  different 
cavities  of  the  body. 

(18)  If  a  viscus  of  a  certain   thickness  and  density  lie 
directly  behind  another  of  the  same  density,  their  shadows  will 
be  superimposed  upon  the  Fluoroscope  and  the  result  will  be  a 
single  dark  shadow  ; — on  the  other  hand,  with  the  Phonendo- 
scope we  are  able  to  differentiate  such  viscera  and  to  outline 
them  separately  upon  the  surface  of  the  body  with  as  much 
facility  as  if  they  were  transparent.     This  is  accomplished  by 
examining  the  superficial  viscus  first  and  then  the  deeper  one. 
It  is  important  in  this  case  to  apply  the  Phonendoscope  at  a 


56  X-Ray  and  the  Phonendoscope. 


place  where  the  superficial   viscus  comes  into   direct  contact 
with  the  body  wall. 

(19)  A  solid  viscus  or  a  viscus  filled  with  fluid,  situated 
behind  a  hollow  viscus,  will  throw  a  lighter  shadow  upon  the 
Fluoroscope  in  proportion  to  the  thickness  of  the  hollow  viscus. 
In  using  the  Phonendoscope  the  vibration  of  the  solid  viscus 
will  likewise  be  found  weaker,  the  greater  the  thickness  of  the 
intervening  layer  of  air. 

(20)  If  the  wall  of  a  hollow  viscus  be  thickened   at  any 
point  the  shadow  of  the  viscus  will  be  less  intense  at  the  thick- 
ened point,  for  at  this  point  the  layer  of  air  will  be  less  deep  or 
even  absent  altogether.     In  the  Phonendoscope  the  vibrations 
over  the  thickened  area  will  be  much  more  powerful  than  over 
the  rest  of  the  organ. 

(21)  Finally,   by    using   two    Roentgen    bulbs   and   two 
Fluoroscopes,  corresponding  organs  of  two  individuals  can  be 
examined  and  compared  at  the  same  time.     In  like  manner, 
two  observers  using  two  Phonendoscopes,  can  examine  simul- 
taneously and  compare  the  vibrations  of  corresponding  parts  of 
two  subjects. 

From  the  foregoing  it  will  be  seen  that  these  two  proce- 
dures are  not  only  closely  related,  but  are  even  somewhat  simi- 
lar ;  yet  the  use  of  the  Phonendoscope  has  certain  practical 
advantages  which  are  of  special  importance  to  the  practicing 
physician  and  which  are  not  to  be  found  in  the  present  method 
of  using  the  X-rays.  These  advantages  are  to  be  found  partly 
in  the  nature  of  the  apparatus  and  partly  in  the  clinical  applica- 
tion of  the  instrument. 

The  instruments  required  for  phonendoscopy  are  very  few. 
The  compact  little  instrument  itself,  a  lead-pencil,  some  copy- 
ing-ink and  tracing  paper  to  make  copies  of  the  phonendoscopic 
chart.  The  tip  of  the  finger  produces  the  necessary  vibrations. 
The  apparatus  is  portable,  and  can  be  used  at  any  time  and 
place. 

Clinically,  we  have  already  obtained  results  with  the  Pho- 
nendoscope which  could  not  be  obtained  with  the  X-rays. 

Not  only  are  we  able  to  trace  with  the  Phonendoscope  the 
outlines  of  all  the  viscera,  whether  they  are  situated  near  the 
surface  or  deep  in  the  interior  of  the  body,  whether  they  are 


X-Ray  and  the  Phonendoscope.  57 


solid  or  hollow  or  filled  with  gas  or  fluid,  or  even  if  they  are 
suspended  in  the  interior  of  a  fluid  cavity,  but  it  also  enables 
us  to  locate  the  subdivisions  and  ligaments  of  viscera,  to  deter- 
mine all  kinds  of  movements  of  the  organs  of  the  body  or  altera- 
tions of  their  positions  as  caused  by  their  functional  activity  or 
through  the  action  of  gravitation. 

Kven  an  incomplete  summary  of  the  peculiarities  of  the 
Phonendoscope,  such  as  can  be  given  at  this  time  must  impress 
both  the  practicing  physician  and  the  scientist  with  the  fact 
that  the  instrument  affords  us  a  rapid,  easy  and  harmless 
clinical  procedure,  by  means  of  which  a  projection  of  all  the 
viscera  may  be  traced  upon  the  surface  of  the  body  ;  and  that 
the  instrument  will  become  popular  and  indeed  indispensable 
to  those  who  have  studied  its  use  carefully. 

The  application  of  the  X-rays  constitutes  a  most  perfect 
method  of  controlling  the  results  of  the  Phonendoscope,  and 
there  is  no  doubt  that  the  X-ray  apparatus  will  be  improved  in 
the  near  future  so  as  to  render  their  application  much  easier  and 
the  results  more  complete. 

We  trust  that  Germany,  the  home  of  the  X-rays  will  soon 
realize  this  hope,  for  no  problem  however  complicated  can  long 
remain  a  riddle  to  German  scientists  who  are  ever  mindful  of 
the  proverb  of  the  Tuscan  Academia  del  Cimento,  "  Provando 
e  riprovando." 


THE    PHONENDOSCOPE. 
NATURAL    SIZE    AMD    SECTIONAL    VIEW. 


CHAPTER  V. 


MECHANICAL  DESCRIPTION  OF  THE 
PHONENDOSCOPE. 

The  Phonendoscope  consists  of  the  following  parts  :  A 
solid  metallic  rod,  T,  terminating  in  a  hard  rubber  bottom,  B. 
This  rod  collects  the  vibrations  and  transmits  them  to  a  disc  of 
hard  rubber,  sufficiently  strong  to  withstand  the  pressure  of 
the  rod  when  it  is  applied  to  the  body.  This  disc  comes  into 
contact  with  a  second  and  thinner  one  of  the  same  material, 
capable  of  vibrating.easily.  This  thin  disc  is  set  into  a  mass  of 
metal,  M,  of  the  size  of  a  large  watch.  Between  the  disc  and 
the  mass  there  is  an  air  space,  C. 

The  interior  thinner  disc  is  more  sensitive  ;  the  second 
stouter  disc  can  easily  be  taken  off,  to  uncover  the  interior 
disc.  The  sound  produced  by  the  disc  is  condensed  by  the 
metallic  walls  of  this  air  space,  and  carried  to  the  orifices,  O 
and  O',  in  which  are  fixed  acoustic  tubes,  A  and  A'. 

When  examining  the  interior  of  an  organ  (such  as  the 
ear  or  the  vagina),  it  is  advisable  to  protect  the  small  rod  by  a 
rubber  tube,  so  that  the  sound  is  not  conveyed  away  or  weak- 
ened when  the  rod  is  touching  the  walls  of  the  organ. 

The  ear  tubes  of  India  rubber  have  at  one  end  an  olivary 
ear-tip  ;  the  other  end  bears  the  metal  tube  to  insert  into  the 
holes  of  the  instrument.  If,  instead  of  plain  metal  tubes,  a 
kind  of  forked  tubes  with  several  ends,  are  used,  a  number  of 
persons  can  at  the  same  time,  and  with  one  instrument,  listen 
to  the  sounds  made  by  the  organ. 

The  object  of  this  instrument  is  to  render  audible  all 
sounds  whether  natural  or  caused  by  morbid  conditions  of  the 
human  body  ;  they  can  be  heard  with  much  greater  intensity 
and  within  much  more  narrow  limits  than  it  has  been  possible 
with  the  ordinary  Stethoscope.  At  the  same  time  it  conveys 
with  great  accuracy  the  nature  of  the  sound. 


60  Mechanical  Description  of  the  Phonendoscope. 


The  Phonendoscope  is  useful  for  hearing  : 

(1)  The  sound  of  the  respiratory  organs,  of  the  circula- 
tion of  blood  and  of  the  digestive  organs  in  the  healthy  body 
as  well  as  in  the  sick  subject. 

(2)  The  sounds  made  by  the  muscles,  joints  and  bones. 

(3)  The  sounds  in  the  matrix   at  the  time  of  pregnancy 
and  the  noise  provoked  by  the  foetus. 

(4)  The  sound  of  the  Capillary  circulation. 

(5)  The  slightest  sound  produced  in  any  diseased  condi- 
tion of  the  body  ;  hence  it  is  possible  to  draw  on  the  body  the 
dimensions,  the  position  or  any  alteration  in  the  position  of  the 
various  organs  and  of  the  fluids  which  have  gathered  in  the 
most  important  cavities  of  the  body. 

(6)  The  sounds  in   the  ear,   the  eye,  the  bladder,    the 
stomach,  and  the  intestines. 

The  application  of  the  Phonendoscope  is  quite  easy  ;  it  is 
placed  with  the  outer  disc  on  that  part  which  is  to  be  ex- 
amined, and  one  or  both  the  auricular  tubes  are  placed  to  the 
ear  or  ears.  In  this  way,  both  hands  are  free  and  the  person 
examining  the  body  can  in  the  manner  described  below,  deter- 
mine the  exact  position  and  dimensions  of  an  organ  and  mark 
its  outlines  on  the  body. 

To  get  into  practice  with  the  Phonendoscope,  it  is  recom- 
mended to  listen  at  the  beginning  with  one  ear  only  and  to  in- 
stitute a  comparison  between  the  direct  auscultation  and  the  ex- 
amination made  with  the  binaural  Stethoscope.  The  superior- 
ity of  the  Phonendoscope  compared  with  all  other  instruments 
will  then  be  evident. 

To  examine  extended  parts  of  the  body,  the  instrument  is 
placed  with  outer  disc  on  the  part  to  be  examined. 

To  examine  limited  parts  (for  instance,  the  sounds  of  the 
arteries  and  the  heart),  screw  the  small  rod  into  the  outer  disc 
and  press  the  rod  cautiously  and  gradually  against  the  part  to 
be  examined. 

The  various  degrees  of  sensibility  can  be  obtained  in  the 
following  manner. 

When  applying  the  two  discs  and  only  one  auricular  tube, 
the  instrument  is  the  least  sensitive. 


Mechanical  Description  of  the  Phonendoscope.  61 


By  using  the  two  auricular  tubes  and  applying  both  discs, 
a  medium  degree  of  sensitiveness  is  obtained. 

The  highest  degree  of  sensitiveness  is  obtained  by  remov- 
ing the  outer  disc  and  applying  only  the  interior  disc  and  both 
auricular  tubes. 

Determining  the  outlines  of  the  organs  is  not  done  by  per- 
cussion, but  by  passing  the  forefinger  with  slight  pressure  over 
the  organ  in  question,  pressing  during  this  manipulation  the 
Phonendoscope  with  the  small  rod  against  the  organ. 

The  following  precautions  are  to  be  observed  : 

When  examining  the  body,  contact  with  clothes  or  other 
objects  is  to  be  avoided. 

Press  slightly  and  gradually  with  the  instrument  against 
the  part  to  be  examined ,  in  order  to  secure  a  direct  contact. 

Avoid  shocks  or  undue  pressure  on  the  interior  disc. 

Both  auricular  tubes  are  always  to  be  inserted  in  the  in- 
strument, even  when  one  tube  only  is  required. 

In  comparison  to  the  Stethoscopes  the  Phonendoscope 
offers  the  following  advantages  : 

(1)  Quick   and  reliable   examination  of  one   or  several 
organs. 

(2)  Possibility  of  a  summary,  but  exact  examination,  as 
well   of  dressed    persons.     In  this  case   hold    the  instrument 
tight  to  avoid  a  rubbing  at  the  clothes. 

(3)  Possibility  of  remaining  distant  from   the   patient, 
which  is  of  considerable  h}'gienical  advantage  to  the  physician 
and  more  convenient  to  the  patient. 

(4)  Exclusion  of  disturbances  through  other   noises  in 
the  examination  room. 

(5)  Possibility  of  determining  the  outlines  of  the  organs 
and  drawing  of  same  on  the  skin  by  marking  the  outlines  with 
a  colored  pencil. 

The  Phonendoscope  offers  a  certain  method  of  detecting 
people  who  feign  deafness.  By  placing  the  hard  rubber  tips 
in  their  ears,  knocking  gently  on  the  rubber  disc,  let  them  tell 
in  which  ear  they  hear  the  noise,  then  press  that  tube  with 
thumb  and  finger  without  patient's  knowledge  ;  the  sound  is 
obstructed  and  simulation  detected. 


PROF.    BIANCHI    OBTAINING    THE    OUTLINES    OF    THE    LIVER 
BY    MEANS    OF   THE    PHON E N OOSCOPE. 

E,  Stomach  ;  F,  Liver  ;  C,  Heart ;  P,  P,  Lobes  of  the  left  lung ; 
R,  Spleen. 


THE  PHONENDOSCOPE  AND  THE  DIGESTION  OF 

FLUIDS. 

By  Felix  Regnault,  M.  D.,  France. 

The  physician  who  would  acquire  a  knowledge  of  the  con- 
dition of  the  organs  of  the  human  body  must  use  his  ears  for 
that  purpose,  in  order  that  he  may  hear  and  understand  the 
sounds  produced,  which  are  called  into  existence,  whilst  these 
organs,  and  internal  parts  of  man,  perform  their  various  func- 
tions. But  further  than  this:  The  physician,  by  means  of 
percussion,  may,  himself,  produce  various  sounds  in  these 
organs. 

In  order  to  do  this,  he  places  the  middle  finger  of  his  left 
hand  upon  the  spot,  under  which  the  organ  which  is  to  be 
examined  lies  concealed,  and,  with  the  finger-tip  of  his  right 
hand,  hammers  or  taps  the  middle  finger  of  the  left.  By  this 
procedure  certain  sounds  are  produced  in  the  different  organs: 
as,  for  instance,  a  solid  organ,  like  the  liver,  or  heart,  or  a 
bone,  will  give  a  heavy  or  dull  sound.  If  the  organ  is  light 
or  empty,  as  the  lungs  and  stomach,  then  the  sound  produced 
will  be  hollow  and  sonorous. 

Now,  in  the  course  of  disease,  it  may  happen  that  an 
organ  will  give  off  a  dull  sound  on  percussion,  which,  when  in 
its  normal  condition,  would  be  sonorous.  Thus  it  happens  dur- 
ing the  process  of  certain  diseases  of  the  lungs;  as,  in  pneu- 
monia and  pleurisy,  and  other  infiltrations,  when  the  sounds  of 
percussion  will  be  dull.  In  a  healthy  condition,  the  clear 
resonance  may  be  easily  discerned,  but  this  state  changes  with 
disease,  and,  therefore,  it  requires  a  well-trained  ear  to  be  able 
to  distinguish  the  different  sounds  which  may  be  produced, 
and  thereby  to  ascertain  the  condition  of  any  organ,  so  as  to 
know  whether  it  be  diseased  or  enlarged  or  displaced. 

It  was  the  celebrated  Dr.  Piorry  who  excelled  in  making 
these  distinctions.  He  had  an  instrument  which  he  himself 
invented,  and  thus  was  enabled  to  discern  the  most  subtle  varia- 
tions of  sounds,  and  the  condition  of  the  organs.  This  instru- 


64  The  Phonendoscope  and  the  Digestion  of  Fluids. 


ment  was  the  "Pleximeter."  In  the  process  of  time  Drs. 
Bianchi  and  Bazzi  were  anxious  to  simplify  these  methods  of 
investigation. 

In  order  to  accomplish  their  purpose  they  constructed  a 
new  instrument,  known  as  the  Phonendoscope,  and  by  its  use 
the  ear  is  enabled  to  ascertain  the  most  minute  differences  in 
the  sounds. 

Now,  the  question  arises,  as  to  how  the  various  sounds 
produced  by  percussion,  which  are  scattered  in  every  direction, 
and  are  thus  carried  away  from  the  ear,  which  only  receives  a 
feeble  part  of  the  impulse  of  the  sound-waves,  could  be 
carried  directly,  and  in  full,  to  the  ear  of  the  examiner?  The 
answer  is,  that  an  instrument  is  needed  for  that  purpose — an 
instrument,  which  receives  the  vibrations  in  full  and  conducts 
them,  one  and  all,  to  our  ears.  The  only  instrument  which 
will  accomplish  this  purpose  is  the  "Phonendoscope." 

Now  then,  let  us  make  an  examination  with  this  instru- 
ment. We  will  examine  the  heart.  We  select  a  given  point 
upon  the  chest-wall  with  which  the  heart  ought  to  be  in  direct 
contact  on  the  inside.  It  is  important  that  we  make  this  selec- 
tion, for,  if  a  lobe  of  the  lung  should  happen  to  intervene  be- 
tween the  heart  and  the  outer  wall  of  the  chest,  then  the  in- 
strument could  not  collect  the  sounds  which  are  produced  by 
the  heart,  as  the  greater  part  of  them  would  be  arrested  by  the 
lobe  of  the  intervening  lung.  Now  we  place  the  buUon  of  the 
metallic  rod  upon  the  point  selected,  and  we  hold  and  press  it 
perpendicularly  against  the  thoracic  wall,  and  thus  depress  the 
skin  with  the  instrument.  As  the  second  finger  of  the  right 
hand  remains  free,  we  use  it  to  compress  the  skin,  which  is 
close  to  the  organ  we  examine,  and  tap  it  with  the  point  of  this 
finger.  Thus  the  organ  which  is  situated  beneath  begins  to 
vibrate,  and  these  vibrations  which  the  ear,  unaided  by  any  in- 
strument, cannot  perceive  are  transmitted  to  the  Phonendo- 
scope, where  they  become  concentrated  and  intensified,  and 
from  which,  by  means  of  the  acoustic  tubes  "A."  "A."  are 
accurately  conveyed  to  the  ears.  And,  as  we  remarked  above, 
any  intervening  organ  weakens  the  intensity  of  these  sounds. 
It  does  not,  however,  obliterate  them.  Thus  if  a  pulmonary 
lobe  should  intervene  between  the  heart  and  the  chest- wall,  the 


The  Phonendoscope  and  the  Digestion  of  Fluids.  65 


finger  striking  it  sets  in  vibration  the  heart,    through  the  lung 
which  intervenes. 

We  must  remember  that  every  organ,  which  is  in  immedi- 
ate contact  with  the  external  pariets,  will  show  its  location 
above  the  skin,  by  an  elevation,  and  thus,  their  form  and  con- 
tour may  be  outlined  with  a  colored  pencil. 

The  instrument  invented  by  Dr.  Bianchi,  has  still  another 
advantage,  which  it  shares  with  the  Phonograph,  and,  that  is, 
that  many  persons  can  listen  at  once  by  means  of  several  tubes 
which  may  be  attached  to  it,  which  is  one  of  the  greatest 
advantages  in  clinical  instruction. 

With  the  Phonendoscope  you  can  hear  the  organs  live  and 
move,  for,  in  fact,  all  our  organs  are  in  perpetual  motion,  and 
their  positions  only  differ  when  different  attitudes  are  assumed 
by  the  individual. 

If  we  desire  to  obtain  the  most  favorable  results,  we  should 
examine  phonendoscopically  when  our  subject  is  standing 
upright. 

The  extent  to  which  the  organs  are  in  contact  with  the 
pariets  will  be  marked  by  a  bulging  out,  or  distention,  over 
that  particular  area. 

As  an  example  marking  the  usefulness  of  recent  discover- 
ies, we  have  only  to  refer  to  the  Phonendoscope. 

We  will  now  select  the  human  stomach,  as  an  example, 
on  which  we  can  try  our  skill,  and  realize  the  fruits  of  this 
discovery. 

Heretofore  every  treatise  on  anatomy  has  selected  the  form 
of  the  stomach  as  found  in  the  cadaver.  You  cannot  outline  it 
in  this  way  upon  a  living  subject.  Percussion,  especially, 
seems  to  be  powerless,  in  recognizing  the  greater  curvatures 
of  this  organ,  when  it  is  full  of  food.  But  by  means  of  the 
Phonendoscope  we  recognize  that  the  empty  stomach  is  length- 
ened vertically  more  than  anatomists  have  thought  it  to  be,  and 
when  it  receives  food,  it  stretches  itself  still  more  in  the  same 
direction. 

We  will  now  drink  a  glass  of  water.  Formerly,  it  was 
supposed  that  this  water  did  not  remain  in  the  stomach.  They 
said  there  was  a  special  bundle  of  muscular  fibers,  called  "  La 
Cravate  de  Suisse,"  which  by  their  contraction  made  the 


66  The  Phonendoscope  and  the  Digestion  of  Fluids. 


liquids  pass  directly  from  the  cardiac  to  the  pyloric  end,  /'.  e. 
from  the  oesophagus  to  the  intestines.  This  whole  view,  which 
was  once  entertained,  is  absolutely  erronious,  as  the  "  Cravate 
de  Suisse"  does  not  exist.  The  stomach  retains  liquids  just 
the  same  as  any  other  food.  It  empties  itself  as  it  rises,  or 
draws  itself  up.  as  it  were,  lengthening  or  stretching  itself 
transversely.  The  water  level  rises  and  reaches  the  pyloric 
orifice,  and  thus  the  fluids  empty  themselves  by  degrees,  just 
as  the  lower  curvature  of  the  stomach  rises. 

Thus  you  will  learn  to  appreciate  the  advantage  of  a  dry 
diet  for  weak  stomachs,  because  the  liquid  remains  in  it  the 
same  as  any  other  food  to  be  assimilated. 

The  weight  imposed  on  this  organ  diminishes  in  propor- 
tion as  we  withhold  fluids.  Further,  the  stomach  is  taxed 
more  or  less,  according  to  the  nature  and  character  of  the 
fluids  we  drink.  It  is  particularly  interesting  to  study  the 
variation  of  time  in  the  digestion  of  different  fluids  in  the 
human  stomach.  For  this  very  reason  we  will  be  led  to  recom- 
mend to  dyspeptics  those  liquids  which  are  easily  digested,  and 
cause  the  smallest  amount  of  trouble.  We  owe  our  thanks  to 
Drs.  Bianchi  and  Comte  for  the  employment  of  the  Phonendo- 
scope, with  which  we  can  outline  the  empty  stomach,  when 
it  is  fasting,  as  given  in  figure  "A."  At  the  moment  of  the 
ingestion  of  one  pint  of  fluid  we  have  figure  "  B. "  And 
finally  two  hours  after  the  ingestion  we  have  figure  "  C." 

These  gentlemen  have  published  the  results  of  their  experi- 
ments to  the  Medical  Congress  of  Moscow,  in  a  most  remarkable 
report,  of  which  we  here  affix  an  epitome  for  the  benefit  of  the 
reader. 


SELTZER    WATER. 


WINE. 
DIGESTION    OF   WATER,  WINE,   SELTZER    WATER    AND    TEA. 

A,  Stomach  fasting ;   B,  Form  of  stomach  after  the  ingestion  of  two  pints 
of  liquid  ;   C,  Two  hours  afterward. 


68 


Phonendoscopy   in  Pregnancy. 


PHONENDOSCOPIC  FIGURE  1. 


A,  Points  of  application  for  the  stem  of  the  Phonendoscope  in  the 
vicinity  of  the  white  line  ;  B,  Points  of  application  on  a  lateral  line 
for  the  foetal  location  ;  P,  B,  Pubis  ;  A,  a,  a  and  B,  b,  b,  Lines  indi- 
cating the  proportions  in  the  fall  of  the  vibrations. 


APPLICATION  OF  THE  PHONENDOSCOPE  IN  THE 
COURSE  OF  PREGNANCY. 

By  Dr.  M.  Anastasiades,  of  Calamata,  Greece. 

The  idea  of  using  the  instrument  of  Bazzi-Bianchi,  as  a 
means  of  investigation,  suggested  itself  to  us  in  the  progress  of 
a  case  of  pregnancy.  Our  first  attempt  was  made  at  the  Char- 
ity Maternity  Hospital,  under  the  supervision  of  Professor 
M.  Porack,  to  whom  we  owe  our  sincere  thanks  for  the  kind 
reception  accorded  to  us. 

After  numerous  experiments  we  are  able  to  present  to-day 
a  certain  number  of  observations  which  appear  to  us  as  the 
most  convincing. 

Our  first  efforts  were  made  in  the  course  of  an  advanced 
pregnancy,  and  were  surrounded  with  difficulties,  and  dis- 
couraging in  the  beginning.  However,  after  several  trials,  we 
were  able  to  obtain  results  sufficiently  conclusive,  such  as  are 
presented  in  figure  No.  3,  which  figure  also  represents  our 
first  complete  phonendoscopic  demonstration. 

Before  explaining  our  manner  of  procedure,  we  must  say 
that  the  success  of  the  examination  depends  upon  the  experi- 
ence we  may  have  in  practicing  phonendoscopy.  We  know 
that  the  stem  of  the  Phonendoscope  must  be  applied  quite  per- 
pendicularly to  the  region  which  is  to  be  examined,  in  order  to 
receive  the  vibrations  produced  by  the  rubbings,  according  to 
their  mode  of  undulating  succession  ,  as  the  sounds  are  propa- 
gated in  the  plates  and  the  membranes  in  like  manner.  The 
organ  beneath  the  skin  enters  into  vibration  by  propagation, 
when  it  comes  in  contact  with  the  same  ;  so  that  the  ear  per- 
ceived two  groups  of  vibrations  (those  produced  by  the  integ- 
ment  and  the  others  by  the  organ  to  be  explored)  which  make 
but  one  impression,  being  united  into  one  sound.  But  when 
the  most  external  organ  ceases  to  vibrate,  then  the  sound  pro- 
duced by  the  organ  lying  beneath  this  alone  reaches  the  ear. 
This  is  an  important  point  to  be  noted,  because  it  helps  us  to 
determine  the  situation  of  the  organ  which  lies  beneath. 


Phonendoscofiy  in  Pregnancy. 


PHONENDOSCOPIC  FIGURE  2. 


A,  Points  of  application  01  the  stem  of  the  Phoneudoscope  on  the 
white  line  for  the  uterine  marking  (location).  B,  Points  of  applica- 
tion of  the  stem  for  the  uterine  location,  as  counter-proof.  D,  D, 
Great  and  little  uterine  donicitv.  P,  B,  Pubes. 


Phoneiidoscopy  in  Pregnancy.  71 

It  is  absolutely  necessary  to  know  that  when  the  skin  is 
insufficiently  distended,  or  when  moist  it  is  not  favorable  to 
phonendoscopic  examination  ;  and,  on  the  other  hand,  that 
exaggerated  tension  of  the  external  parts  induces  vibrations 
that  drown  those  of  the  organ  beneath.  It  is  therefore  neces- 
sary that  we  apply  the  stem  and  practice  the  rubbings  in  a 
manner  suited  to  the  physical  condition  of  the  skin,  varying 
according  to  the  individual  requirements,  and,  in  the  same  indi- 
vidual, in  the  different  regions,  etc.,  etc. 

It  is  also  necessary  to  remember  that  the  vibrations,  pro- 
duced in  too  close  a  proximity  to  the  stem,  when  pressure, 
more  or  less  strong,  is  applied,  so  as  to  put  the  skin  in  contact 
with  the  organ  beneath,  which  is  to  be  examined,  are  of  no 
value  whatever.  We  must  also  bear  in  mind  the  fact  that  the 
muscles  enter  into  vibrating  process,  and  give  a  sound  which 
reaches  the  ear,  with  those  of  the  wall,  and  of  the  organs 
beneath.  It  is  necessary,  therefore,  to  pay  the  greatest  atten- 
tion to  that  which  happens  on  the  surface,  but  we  may  say  that 
the  vertical  rubbings,  during  the  examination  of  the  foetal 
regions,  do  not  set  the  fibres  in  action.  In  general,  skin  which 
is  stretched  too  much  causes  vibrations  which  drown  those  of 
the  organs  beneath,  and  skin  too  much  relaxed  gives  no  vibra- 
tions at  all.  Also  to  facilitate  the  examination  we  have  in 
course  of  construction  a  complimentary  appliance  which  will, 
we  hope,  overcome  all  these  difficulties.  As  to  the  rubbings, 
they  must  be  made  with  the  point  of  the  finger,  always  by  suc- 
cessive tappings  (palpations),  going  from  the  inside  outward, 
very  closely  to  the  stem.  It  is  necessary  to  make  a  sort  of 
rubbing  percussion,  starting  from  the  stem  of  the  instrument, 
and  in  going  away  from  it,  following  a  horizontal  line. 

This  is  the  sum  total  of  these  technical  details  which  are 
acquired  only  by  practice.  Let  us  now  pass  to  the  examina- 
tion of  a  pregnant  uterus.  The  pregnant  woman  is  laid  flat 
on  her  back,  the  shoulders  slightly  raised,  after  emptying  the 
bladder  we  apply  the  stem  of  the  instrument  to  the  white  line, 
no  matter  at  what  point,  to  the  umbilicus  for  example,  and 
quite  perpendicularly  to  the  skin's  surface,  and  pressing  more 
or  less,  according  to  the  depth  of  which  we  have  judged  ap- 
proximately the  uterus  is  to  be  found,  and  according  to  the 


Phonendoscopy  in  Pregnancy 


PHONENDOSCOPIC  FIGURE  3. 


Schema  representing  the  great,  the  little  donicity  and  the  foetus  of  a 
pregnancy  of  eight  months,  left  position. 


Phonendoscopy  in  Pregnancy.  73 


thickness  of  the  skin.  We  then  begin  the  rubbings  with  the 
point  of  the  finger,  proceeding  to  make  a  succession  of  close, 
quick  strokes,  starting  at  the  stem,  and  going  away  from  it  in  a 
transverse  line.  When  we  arrive  at  a  point  where  the  sound 
diminishes,  in  a  decided  manner,  we  make  a  mark  with  a 
colored  pencil,  then  repeat  the -same  operation,  following  in  the 
same  horizontal  line  on  the  other  side  of  the  stem.  After  that 
we  continue  the  rubbings  further  on  from  this  point,  and  always 
following  in  the  same  line  until  the  ear  can  no  longer  detect 
any  sound,  then  we  must  mark  this  new  point.  We  repeat  the 
operation  on  a  second  horizontal  line  three  centimeters  from 
the  vertical,  above  the  preceding,  and  on  the  entire  length  of 
the  white  line  above  and  below  the  umbilicus.  To  obtain  the 
exact  limits,  and  by  way  of  control,  we  perform  the  same  series 
of  operations,  following  two  vertical  lines,  each  traced  parallel 
by  three  or  four  centimeters  to  the  right  and  left  of  the  middle 
umbilical  line.  We  thus  obtain  two  series  of  marks,  the  ones 
corresponding  to  the  points  where  the  sound  diminishes 
abruptly,  and  the  others  to  those  where  it  ceases  altogether. 
We  unite  the  marked  points,  and  thus  obtain  two  concentric 
curves  or  cycloforms,  which  present  the  figure  of  the  uterus, 
giving  in  a  way  the  outlines  of  a  vertical  curve,  and  following 
its  anterior  surface.  The  interior  curve  corresponds  to  the 
part  of  the  uterus  which  is  in  contact  with  the  abdominal  wall, 
it  is  the  little  uterine  echo  chamber  of  the  foetal  sounds  or  vibra- 
tions. The  large  curve  corresponds  to  the  parts  which  run  from 
the  wall ;  it  is  the  great  echo  chamber  of  the  same  sounds. 

The  depth  of  the  uterus  answers  to  the  mark  which  joins 
the  extreme  superior  points  ;  but  for  greater  exactness  we  can 
outline  neighboring  organs.  This  we  accomplish  by  making  a 
series  of  rubbings  directed  from  below7  upwards  on  the  middle 
and  lateral  lines  already  traced.  A  little  practice  will  enable 
us  to  make  these  various  operations  with  great  rapidity.  In 
this  manner  we  locate  the  uterus.  Now  how  can  we  locate  the 
foetus  ?  For  locating  the  foetus  we  place  the  woman  on  her 
knees,  near  the  edge  of  the  bed,  make  her  bend  over,  being 
supported  by  the  shoulder  of  some  one  placed  in  front  of  her, 
or  on  any  kind  of  support  in  such  a  way  so  that  the  body 
makes  a  sharp  angle,  in  a  horizontal  attitude,  so  that  the  opera- 


74 


Phonendoscopy  in  Pregnancy 


PHONENDOSCOPIC  FIGURE  4. 


Schema  representing  a  gemillaire,  or  twin  pregnancy  of  eight  and  a-half 
months,  amniotic  liquid  in  excess;  U,  Uterus;  O,  Umbilicus; 
N,  Zone  neutral ;  T,  T  Foetal  heads ;  G,  Lines  showing  the  head 
and  body  ;  e,  e,  e,  Unsteady  foetal  inferior  extremities. 


Phonendoscopy  in  Pregnancy.  75 


tor  may  be  able  to  make  his  examination  more  freely.  It  is 
true  that  by  this  position  the  abdominal  walls  are  more  or  less 
stretched,  but  we  must  try  to  modify  this  condition  by  changing 
the  position  of  the  subject  now  and  then,  so  as  to  lessen  the 
contractions.  In  this  position  the  uterus  swings  and  comes 
against  the  abdominal  wall,  except  in  its  most  inferior  part. 
For  the  phonendoscopic  research  of  the  foetus,  we  take  two 
lines  chosen,  after  a  preliminary  palpation,  which  indicates  the 
region  of  most  resistance,  lines  which  we  follow,  as  for  the 
determination  of  uterine  sound  limits.  The  stem  of  the  instru- 
ment being  placed  we  make  the  rubbings  by  going  from  the 
inside  outward,  long,  vertical,  and  quite  hard.  Where  the 
sound  changes  we  mark  a  point ;  then  recommence  the  same 
operations  as  for  the  sound  limits,  the  divers  points  thus  ob- 
tained are  compared  to  each  other,  and  mark  the  foetal  line. 

For  this  foetal  "  schema"  or  figure  it  is  to  be  noted  that 
the  kneeling  position  is  the  most  favorable,  because  in  this 
position,  the  foetus  comes  in  contact  with  the  anterior  wall  of 
the  uterus,  and  by  its  own  weight  displaces  the  amniotic  liquid. 
However,  the  inferior  part  of  the  uterus  is  kept  away  from  the 
wall,  and  in  order  to  explore  it,  it  is  necessary  that  the  dorsal 
position  be  assumed,  the  seat  being  sufficiently  elevated.  This 
is  done  after  having  traced  the  schema  or  figure  of  the  superior 
part,  according  to  the  first  position.  In  the  horizontal  posi- 
tion only  can  we  obtain,  sometimes,  the  entire  foetal  schema 
or  form;  thus  it  is  that  schema  or  figuie  No.  i  was  obtained 
complete  in  these  two  positions.  But  we  often  meet  with  difficul- 
ties, when  the  foetus  is  very  unsteady,  or  when  the  amniotic 
liquid  is  very  abundant,  as  was  the  case  in  schema  or  figure 
No.  2,  which  we  could  not  have  obtained  otherwise  than  in  the 
kneeling  position.  (It  is  generally  necessary  to  know  how  to 
combine  the  two  positions.)  We  here  produce  three  schemas 
which  represent  the  same  foetus.  In  one  case,  as  you  see,  we 
have  been  able  to  diagnosticate  a  gemillaire  or  twin  pregnancy. 
It  would  be  very  difficult  for  us  to  say  just  now  what  place 
this  mode  of  obstetrical  examination  will  hold  in  comparison 
with  the  palpation,  soundings  and  other  processes.  However, 
it  seems  to  us  that  the  results  already  obtained  are  sufficient  to 
say  that  phonendoscopy  will  be  of  real  service,  not  only  in  the 


Phonendoscof>y  in  Pregnancy. 


PHONENDOSCOPIC   FIGURE  5. 


Foetal  schema,  right  position,  pregnancy  complete, 
abdominal  wall  very  thick. 


Phonendoscopy   in  Pregnancy.  77 


diagnosis  of  simple  cases  of  pregnancy,  i.  e.,  normal  cases,  but 
more  especially  in  cases  of  hydrocephalus,  and  twin  pregnan- 
cies, and  of  various  anomalies  of  the  uterus,  etc.,  where  the 
other  modes  of  examination  are  very  often  without  avail. 


BAZZI=BIANCHI 


Patented  in  I .  S.  A.  and  most  of  the  civilized  countries 


Trade-Hark  "  PHONENDOSCOPE"  registered  in 
U.  S.  Patent  Office 


GEORGE  P.  PILLING  &  SON 

PHILADELPHIA 

the 


HECTOR  T.FENTON,.PH.LADELPHIA 

Patent  Counsel  (J.   5.   A. 


BEWARE  OF  IMITATIONS 

All    Genuine    Instruments    sold    in    U.  S.  A.    stamped 
with  our  name. 


PRICES  OF  THE 

PHONENDOSCOPE 


NO.     2    CASE.       VELVET    LINED 


In  No.  1  Case,  $3.75 


In  No.  2  Case,  $4.00 


May  be  purchased  from  your  surgical  dealer,  or,  if  not  in  stock, 
from  us  direct. 

GEORGE  P.  PILLING  &  SON 

1225-21=29  Callowhill  Street 

PHILADELPHIA,  U.  5.  A. 

MARTIN  WALLACH,  Nachfolger,  Cassel,  Germany  and  Rome,  Italy 

European  Agents  for  P.ionandoscope 


Phonendoscope 


-CHILDREN'S  SIZE 


OOME  time  ago  we  were  urgently  requested  to 
.  manufacture  a  smaller  size  of  the  Phonendo- 
scope. We  hesitated,  not  wishing  to  vary  from  the 
Bazzi-Bianchi  standard,  but  finally  made  up  a  few, 
exactly  same  style  and  proportions  as  the  standard 
but  about  three-quarters  the  size.  We  forwarded 
one  of  these  to  Martin  Wallach,  Nachfolger,  and  Prof. 
Aureli  Bianchi.  Both  Wallach  and  Prof.  Bianchi 
report  very  favorably  and  recommend  it  for  children's 
use.  We  therefore  designated  this  as  the  "CHILD'S 
SIZE"  and  it  should  be  so  stated  when  ordering. 
We  do  not  want  to  complicate  ordering,  so  please 
notice  that  in  ordering  the  regular  standard  Phonen- 
doscope it  is  not  necessary  to  state  size,  AS  THE 

STANDARD  WILL  ALWAYS  BE  SENT  unless   "Child's 

Size,"  is  specified. 

Prices  of  Child's  Size,  same  as  Standard 


GEORGE  P.  PILLING  &  SON 

Sole  Agents  for  U.  S.  A.  PHILADELPHIA,    PA. 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


FEB  1 6  1998 


3  1970  00592  4656 


A  000  501  415  4 


WGlUl 

B577P 
1898 


Bianchi,  Aurelio. 
The  phonendoscoT>e. 


WG141 

B577P 
18  )3 


Bianchi,  Aurelio. 
The  jhonendoscope, 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


